The Comprehensive Stuttering Therapy Program : Development & Initial Outcomes

1. The Comprehensive Stuttering Therapy Program : Development & Initial Outcomes Farzan Irani Assistant Professor Department of Communication Disorders “Share & Tell” College of Health Professions February 16th, 2012

2. OUTLINE • Discussion of Objectives/Learner Outcomes • CSTP-A Overview • History & Development • Research Objectives • Program Structure • Initial Outcome Data • Discussion/Evaluation of Program • Future Clinical and Research Directions

3. OBJECTIVES • As a result of this presentation participants will be able to: • Describe the nature of stuttering. • Identify methods to behaviorally assess and treat stuttering. • Identify the pros and cons of intensive therapy for adults who stutter. • Identify the importance of providing regular follow-up therapy for clients attending an intensive stuttering therapy program. • Identify the pros and cons of providing therapy for Adults Who Stutter via telepractice.

4. STUTTERING • Let’s see! • Core & Secondary behaviors • Often described as an “Iceberg” • A-B-C http://www.citylit.ac.uk/resources/media/image/Iceberg.jpg

5. BEHAVIORAL ASSESSMENT • Important to measure: • Severity of overt behaviors. • Impact of stuttering on communication attitude and Quality of Life (QOL). • Measures of severity: • Calculating Percentage of Syllables Stuttered (%SS) from a variety of speech samples. • Stuttering Severity Instrument – 4th Edition (SSI-4). • Measures of Communication Attitude & QOL: • Erickson S-24 Scale of Communication Attitudes (S-24) • Overall Assessment of the Speakers Experience of Stuttering (OASES). • Both questionnaires to be completed by the client/participant.

6. BEHAVIORAL TREATMENT • Important to remember that stuttering is a multidimensional disorder –hence treatment must address all aspects: • Stuttering Severity: Addressed by the use of a variety of methods to enhance the forward flow of speech and fluency. • Attitudes and QOL: Addressed by the use of Cognitive Behavioral Therapy principles, Mindfulness, and more recently the use of principles from “Acceptance and Commitment Therapy” and “Dialectical Behavioral Therapy.” • Very limited data to support the benefits of addressing attitudes and QOL; however, it is strongly recommended by newer qualitative studies, anecdotal data, self-help/advocacy groups, and experiential experts.

7. CSTP-A: HISTORY & DEVELOPMENT • Offered at Texas State University – San Marcos in Summer 2011 for the first time. • Largely influenced and builds on the Intensive Stuttering Clinic for Adolescents and Adults (ISCAA) offered by Rodney Gabel Ph.D., BRS-FD since 2003. • Developed and builds from my research and clinical experiences: • Investigation and application of telepractice follow-up to supplement Intensive Stuttering therapy (Irani & Gabel, 2011). • Qualitative investigation of factors that client report as helpful and not helpful in the therapy process (Irani, 2010; unpublished dissertation). • The need for better documentation and reporting of clinical outcome data. • Developed during 2010 as part of a fluency cognate for graduate students in the Department of Communication Disorders • Purpose of the program: • Offer quality services for clients. • Increase/improve student training and clinical education in the area of fluency disorders. • Develop a systematic research program to assess: a) Treatment outcomes for intensive stuttering therapy; b) Treatment outcomes for telepractice; c) Evaluate student learning as part of participating in an intensive therapy program.

8. RESEARCH OBJECTIVES • Measure quantitative and qualitative treatment outcomes that account for the multifaceted nature of stuttering, including: • Measures of stuttering severity including the Stuttering Severity Instrument, 4th Edition (SSI-4), and percentage of syllables stuttered (%SS) in a variety of speaking tasks, client and clinician perceptual ratings of stuttering severity. • Measures of the clients’ attitudes toward speech and communication and impact on Quality of Life measured the Erickson’s S-24 scale of communication attitudes and the Overall Assessment of the Speaker’s Experience of Stuttering (OASES, Yaruss & Quesal, 2008) . • Qualitative Data gathered from: • Clients • Graduate Student Clinicians.

9. RESEARCH OBJECTIVES • Secondary research objective: Student learning outcomes and clinical preparation. • Qualitative study under development • Semi-structured interviews • Gather student perceptions of benefits from participating in the program, including: academic, clinical, and other benefits derived from this program. • All interviews to be conducted after completion of the program .

10. PROGRAM STRUCTURE

11. STRUCTURE– INTENSIVE CLINIC • 10-days (2-weeks) • Programmatic in nature • Includes manual, adapted from ISCAA manual developed by Rodney Gabel. • Flexible to accommodate unique client needs during individual sessions. • Total 60 hours of therapy • 20 hours group therapy; 10 AM to 12 PM (program coordinator/supervisors) • 40 hours individual therapy 1 PM to 5 PM (student clinicians) • 5 days/per week • 3 follow-up sessions the week following Intensive Clinic • Supports transfer and stabilization of skills learned during the intensive clinic

12. STRUCTURE– INTENSIVE CLINIC • Goals Addressed (overlap present): • Education • Awareness/identification • Desensitization • Mindfulness • Fluency Shaping • Stuttering Modification • Becoming one’s own clinician (transfer & maintenance of skills)

13. STRUCTURE: FOLLOW-UP • Tailored to individual client needs. • Preferably offered via telepractice to accommodate for Scheduling conflicts and distance from clinic (overall cost). • Offered for up to 10 months (2 academic semesters) after completion of the Intensive Clinic. • At least one semester of follow-up strongly recommended for all clients. • Research indicates (St. Louis & Westbrook, 1987; Andrews, Guitar, & Howie; Irani, 2010) that intensive programs are good for quick gains; however, follow-up therapy is important to long-term maintenance of gains.

14. TELEPRACTICE DEMONSTRATION

15. INITIAL OUTCOME DATA • Program will be completed in May 2012. • 3 clients attended the program in Summer 2011, and continue receiving follow-up services. • Data collection, organization, and analysis is still underway. • Initial outcome measures gathered from the baseline sessions, intensive clinic, and first semester of follow-up are presented. • Qualitative interviews to evaluate the intensive clinic completed. Data is not available at this time. • A second interview to evaluate the follow-up program will be conducted after its completion in May. • Qualitative interviews with students will be completed after the program completion in May 2012.

16. DATA ANALYSIS • Descriptive data presented (visual where possible) • Dataset analyzed statistically includes the following measures: • Severity Measures (%SS for conversation, monologue, and reading & SSI-4). • Attitude Measures (S-24 & OASES). • All %SS data independently analyzed by 2 trained RA’s • Intra-Class Correlation Coefficient (ICC, Shrout & Fleiss, 1979) calculated • ICC (2, 1)=.854, p=.000. • Wilcoxon Signed-Ranks test used to measure statistically significant changes in outcome measures (non-parametric selected due to small n). • Statistics done for major data points including pre-intensive (pre), Post-Intensive (post); follow-up 1 (F1), and follow-up 2 (F2). • Non-parametric equivalent of t-test.

17. DATA POINTS Pre F2 Post F1

18. PARTICIPANT PROFILE • 3 clients: 2 male, 1 female • Age ranged from 17:12 years to 43 years • Stuttering severity at baseline (SSI-4) ranged from Mild to Very Severe • Quantitative data available for baseline measures, post-intensive, and 6 month follow-up. • Includes SSI-4 scores, %SS, S-24, and OASES. • OASES and S-24 scores only gathered at major data points to address test-retest reliability.

19. DESCRIPTIVE DATA: %SS CONVERSATION

20. DESCRIPTIVE DATA: %SS MONOLOGUE Cohen’s d = .69 Cohen’s d = 1.83

21. DESCRIPTIVE DATA: %SS READING Cohen’s d = .97

22. DESCRIPTIVE DATA: SSI-4 MODERATE MILD Cohen’s d = .54 Cohen’s d = .56

23. DESCRIPTIVE DATA: S-24 Cohen’s d = .72 Cohen’s d = 2.94

24. DESCRIPTIVE DATA: OASES Cohen’s d = 1.83 Cohen’s d = 2.25

25. RESULTS: STATISTICAL ANALYSES • Wilcoxon Signed-Ranks Test conducted to measure whether treatment resulted in statistically significant changes in a variety of outcome measures: • Severity (based on %SS and SSI-4) • Intensive Clinic, Pre-Post Comparison: Z= -2.982, p=.003 • Follow-up, Pre-F2 Comparison: Z=-2.407, p=.016 • Attitude Change (based on OASES and S-24) • Intensive Clinic, Pre-Post Comparison: Z=-1.051, p=.293 • Follow-up, Pre-F2 Comparison: Z=-2.201, p=.028

26. EVALUATION • Initial outcomes data indicates the intensive clinic and follow-up package were effective. • Statistically & Clinically significant changes made at 6 mo. follow-up • Intensive clinic good for making gains in outcomes related to stuttering severity. • Follow-up services important to maintaining outcomes related to severity and improving outcomes related to attitudes toward speech/communication. • Both components of the program appear to help with different aspects of stuttering management: • Intensive appears to help make rapid changes in severity measures and begin the process of attitude change. • Follow-up helps with maintenance of speech related changes and continued improvement with regards to attitude change. • Telepractice appears to be an effective means to deliver follow-up, no comparison data available at this time.

27. INTERESTING TRENDS • Pre-Post Intensive Clinic: • Significant changes on all outcome measures of overt behavior (frequency of stuttering, severity) • Clinically significant changes on outcome measures of attitude; however, comparatively small magnitude as measured by Cohen’s d • 6-month follow-up data: • Reduction in the magnitude of change on all outcome measures of overt behavior as measured by Cohen’s d. • Increased magnitude and significance on all outcome measures related to attitude. • Outcomes data appears to conflict! • Qualitative interview = missing piece. • Often, as clients become more comfortable with stuttering (increased acceptance) they “take control” and modify their stuttering behaviors. Quantitative data appears to show relapse as a result. • Stuttering variability needs to be accounted for.

28. FUTURE DIRECTIONS • Major limitation = n • Continue data collection over a period of years to increase n. • Continue to offer the program as a package with future changes: • Inclusion of adolescents • Flexibility with follow-up program: choice between in-person and telepractice • Allow for comparison between telepractice and regular follow-up therapy. • Possibly offer a “hybrid” version of the program where contact time during the intensive is reduced to ~5 days. • Part of the intensive program offered as a series of online modules. • Offer an online only version of the CSTP, compare with existing CSTP outcomes data.

29. ACKNOWLEDGMENT • CHP Start-up Monies supported the Clinical Program • Texas State University – San Marcos Research Enhancement Program (REP) supported Research Program and supplemented CHP Start-up money. • Department of Communication Disorders for supporting this project. • Speech-Language-Hearing Clinic and CDIS graduate students for involvement. • Special thanks to: • Dean Ruth Wellborn & Dr. Diana Gonzales for making the project possible. • Ms. Renee Wendell for supporting the program as clinical director. • Ms. Irene Talamantes for administrative help, and general help setting up the program, providing direction! • CDIS graduate Students: Heather Ballard, Virginia Davenport, Katrina Harris, Halya Lenard, and Brooke Lenard for their hard work and devotion. • Dr. Eric Swartz from Texas A&M University at Kingsville for supervision support during the intensive clinic.

30. THOUGHTS? QUESTIONS? • My Contact Information: • firani@txstate.edu; (512)245-6599 • Yes, the CSTP will be offered again this summer. Adolescents, age 12 years and above are welcome  • www.health.txstate.edu/slhclinic/cstp.html