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:
1. I enjoy communicating.
1 2 3 4 5 6 7
Strongly Mildly Mildly Strongly
Disagree Disagree Disagree Neutral Agree Agree Agree
2. I feel comfortable as a speaker.
1 2 3 4 5 6 7
Strongly Mildly Mildly Strongly
Disagree Disagree Disagree Neutral Agree Agree Agree
3. I like the way I sound.
1 2 3 4 5 6 7
Strongly Mildly Mildly Strongly
Disagree Disagree Disagree Neutral Agree Agree Agree
4. I feel I can modify my speech in even the toughest situations.
1 2 3 4 5 6 7
Strongly Mildly Mildly Strongly
Disagree Disagree Disagree Neutral Agree Agree Agree
5. I am satisfied with my overall speech fluency.
1 2 3 4 5 6 7
Strongly Mildly Mildly Strongly
Disagree Disagree Disagree Neutral Agree Agree Agree
Behavioral Components
1. I avoid speaking situations.
1 2 3 4 5 6 7
More than Almost
Never rarely Sometimes half-the-time Half the time Always Always
2. I avoid words.
1 2 3 4 5 6 7
More than Almost
Never rarely Sometimes half-the-time Half the time Always Always
3. My speech is becoming more fluent.
1 2 3 4 5 6 7
Strongly Mildly Mildly Strongly
Disagree Disagree Disagree Neutral Agree Agree Agree
4 I use fluency-enhancing techniques or strategies.
1 2 3 4 5 6 7
More than Almost
Never rarely Sometimes half-the-time Half the time Always Always
5. When I stutter I do things such as blink my eyes, look away, and shake my head.
1 2 3 4 5 6 7
More than Almost
Never rarely Sometimes half-the-time Half the time Always Always
Cognitive Components
1. I need speech therapy.
1 2 3 4 5 6 7
Strongly Mildly Mildly Strongly
Disagree Disagree Disagree Neutral Agree Agree Agree
2. My speech negatively affects my vocational success.
1 2 3 4 5 6 7
Strongly Mildly Mildly Strongly
Disagree Disagree Disagree Neutral Agree Agree Agree
3. My speech negatively affects my social success.
1 2 3 4 5 6 7
Strongly Mildly Mildly Strongly
Disagree Disagree Disagree Neutral Agree Agree Agree
4. I understand my stuttering problem.
1 2 3 4 5 6 7
Strongly Mildly Mildly Strongly
Disagree Disagree Disagree Neutral Agree Agree Agree
5. I am doubtful if stuttering therapy can help me.
1 2 3 4 5 6 7
Strongly Mildly Mildly Strongly
Disagree Disagree Disagree Neutral Agree Agree Agree
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.
Affective Components
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