Treatment Effectiveness: Finding Value in Clinical Data. Part 1.

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

2. 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

3. But…what is the nature ofthe client’s complaint? An effective treatment is onethat successfully addressesthe client’s complaint

4. 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

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

6. 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...

7. 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

8. The complaintas 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

9. 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.

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

11. 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...

12. 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

13. 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

14. 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 operationalizedto permit rigorous study (at present)

15. 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

16. 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