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
OUTLINE
 Discussion of Objectives/Learner Outcomes
 CSTP-A Overview
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History & Development
Research Objectives
Program Structure
Initial Outcome Data
 Discussion/Evaluation of Program
 Future Clinical and Research Directions
OBJECTIVES
 As a result of this presentation participants will be able to:
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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.
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
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.
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.
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:
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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:
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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.
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.
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 .
PROGRAM STRUCTURE
STRUCTURE– INTENSIVE CLINIC
 10-days (2-weeks)
 Programmatic in nature
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Includes manual, adapted from ISCAA
manual developed by Rodney Gabel.
Flexible to accommodate unique client
needs during individual sessions.
 Total 60 hours of therapy
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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
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Supports transfer and stabilization of
skills learned during the intensive
clinic
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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)
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.
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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.
TELEPRACTICE DEMONSTRATION
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.
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.
DATA POINTS
Pre
F2
Post
F1
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, postintensive, 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.
DESCRIPTIVE DATA: %SS
CONVERSATION
%SS Conversation
18.00
15.90
16.00
14.13
12.00
13.46
13.33
14.00
11.83
11.23
10.00
%SS Conversation
6.33
8.00
6.00
4.00
Cohen’s d = .64
2.00
Cohen’s d = 1.83
0.00
Baseline 1
Baseline 2
Baseline 3
Pre
Post
F1
F2
DESCRIPTIVE DATA: %SS
MONOLOGUE
%SS Monologue
20.00
18.27
18.00
16.00
14.20
14.97
13.27
14.00
12.13
12.00
11.50
10.00
%SS Monologue
7.63
8.00
6.00
Cohen’s d = .69
4.00
2.00
Cohen’s d = 1.83
0.00
Baseline 1
Baseline 2
Baseline 3
Pre
Post
F1
F2
DESCRIPTIVE DATA: %SS READING
%SS Reading
16.00
13.63
14.00
11.70
12.00
10.00
11.77
9.47
7.90
8.00
%SS Reading
6.00
3.90
4.00
3.55
Cohen’s d = .36
2.00
Cohen’s d = .97
0.00
Baseline 1
Baseline 2
Baseline 3
Pre
Post
F1
F2
DESCRIPTIVE DATA: SSI-4
SSI-4
30.00
27.67
MODERATE
26.33
24.67
25.00
22.67
20.33
20.00
MILD
19.00
18.67
15.00
SSI-4
Cohen’s d = .54
V. MILD
Cohen’s d = .56
10.00
Intensive
5.00
Withdrawal
0.00
Baseline 1
Baseline 2
Baseline 3
Pre
Post
F1
F2
DESCRIPTIVE DATA: S-24
S-24
18.00
16.00
16.00
14.00
12.67
12.33
12.00
10.00
7.33
8.00
6.00
4.00
2.00
0.00
Pre
Post
F1
Cohen’s d = .72
Cohen’s d = 2.94
F2
S-24
DESCRIPTIVE DATA: OASES
OASES
5.00
4.50
SEVERE
4.00
3.50
MOD/SEVERE
3.12
3.00
2.50
2.00
MOD
2.11
2.20
Post
F1
1.95
MILD/MOD
1.50
1.00
0.50
MILD
0.00
Pre
Cohen’s d = 1.83
Cohen’s d = 2.25
F2
OASES
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
EVALUATION
 Initial outcomes data indicates the intensive clinic and follow-up
package were effective.
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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:
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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.
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Telepractice appears to be an effective means to deliver follow-up, no comparison
data available at this time.
INTERESTING TRENDS
 Pre-Post Intensive Clinic:
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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:
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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!
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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.
FUTURE DIRECTIONS
 Major limitation = n
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Continue data collection over a period of years to increase n.
 Continue to offer the program as a package with future changes:
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Inclusion of adolescents
Flexibility with follow-up program: choice between in-person and telepractice
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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.
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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.
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:
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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.
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
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– www.health.txstate.edu/slhclinic/cstp.html