Evidence-based Clinical Guidelines for Stuttering

About the Authors

Leonoor OonkLeonoor Oonk (University of Applied Sciences Utrecht, the Netherlands) is a Speech and Language Therapist (SLT) specialised in fluency disorders and holds a MSc in Clinical Language, Speech and Hearing Sciences. She has been working for many years with people who stutter (PWS).  She has been chair of the working group that developed the Dutch Evidence-based Clinical Guidelines for Stuttering.  She is a lecturer at the Utrecht University of Applied Sciences and has been active as a board member of the Dutch joint association for public information about stuttering (NFS).
Bert BastBert Bast holds a PhD in Immunology and retired a couple of years ago, as associate professor and head of the clinical laboratory of Immunology at the University Medical Center Utrecht. He is a PWS. He is chair of the joint scientific committee of the Dutch stuttering associations (clients: Demosthenes; professionals: NVST), chair of their joint organization as to public information (NFS), was chair of the scientific program committee of the last ISA World Congress (Lunteren, Nl) in 2013, serves as secretary within the ISA board and has recently joined the scientific committee of the IFA.
Joeri van OrmondtJoeri van Ormondt (Dutch Stuttering Association, Demosthenes), holds a Master of Science degree in Management.  As a member of the working group of the Dutch Evidence-based Guideline for Stuttering he contributed to the guideline. Furthermore he wrote the patient version of the guideline and researched how that patient version enhances self-management of PWS. He is set to become an SLT in February 2016 and is a PWS.

Mark Pertijs, is an SLT and holds a Master of Science degree in Clinical Language, Speech and Hearing Sciences. As an SLT he has extensive experience in working with PWS. He is a lecturer at Utrecht University of Applied Sciences and a member of staff of the European Clinical Specialization Fluency Disorders. As a project manager he is involved in the developmental process and implementation of the Dutch Evidence-based Guideline for Stuttering in cooperation with the CBO Dutch Institute for Healthcare Improvement, the Dutch association for fluency specialists (NVST) and the Dutch association for SLTs (NVLF).

What is an evidence based guideline?

  • Guidelines have become essential in clinical practice, be it for broken legs or psychosis. Such guidelines embody shared knowledge on a specific problem. Guidelines in speech and language therapy are not very common. Treatment may differ from therapist to therapist, be it based on differences in vocational training, clinical experience or preferences, or otherwise. For example: Imagine a three year old child who starts to stutter. The parents consult a Speech and Language Therapist (SLT) and are advised to start therapy immediately. Reason: you should start young to get the best results. Suppose the parents, after having received this advice, move to another area and consult another SLT. This SLT advises to wait and see. In many young children, recovery from stuttering will occur naturally. Both SLTs may be correct in general terms, but the parents are confused.

Guidelines are valuable tools for speech therapists, fluency specialists, educational institutions and health care providers who work with people who stutter and for people who stutter and their families. They can help to improve the quality of care and minimize undesirable differences in treatment and management of PWS.

An Evidence-based clinical guideline is a document with recommendations. An example of one of our recommendations:

“The treatment of children who begin to stutter before the age of four, should start before they become five years of age.”

Such recommendations are based on a systematic review of scientific research, as well as a critical appraisal of the evidence available and an assessment of the benefits and harms of alternative care options (Graham R, Mancher M, Wolman DM, Greenfield S, Steinberg E, editor(s). Clinical practice guidelines we can trust. Washington (DC), http://www.iom.edu/Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust/Standards.aspx.

In the Netherlands, we have recently developed an evidence-based guideline for stuttering.

Development of the Dutch evidence-based clinical guideline for stuttering

Participants

The Dutch guideline for the treatment and management of developmental stuttering has been created by a working group of ten participants, consisting of SLTs (1), SLTs specialized in fluency disorders (5) and PWS (2), in cooperation with experts (2) of the CBO, an independent Dutch institute for healthcare improvement which is specialized in the methodology and techniques underlying the development of guidelines (www.CBO.nl).

We have been working with representatives from various backgrounds to guarantee that the three elements of evidence-based practice were properly represented.

These three elements are

  1. External scientific evidence
  2. Clinical expertise
  3. The patient perspective
perspective-evidence-expertise

Figure 1: The three elements of evidence-based practice

All three elements are important in the decision making process in clinical practice. Therefore they are relevant in making decisions about recommendations of the care concerning stuttering. The patient perspective is an important factor to be taken into account when the benefits and harms of different care options are being assessed.

To increase public support for the guideline, two additional groups were involved:

  1. The advisory group (n=7). This group consisted of professional associations involved with PWS such as general practitioners, specialists, teachers and psychologists. They played an important role during the problem analysis and during the external review stage.
  2. The focus group (n=11); a group of PWS and parents of Children Who Stutter (CWS). They also played an important role during the problem analysis and gave in depth information about the way they experience stuttering health care.

Questions

A survey was held amongst SLTs, stuttering specialists and PWS and their parents, to find out more about the existing problems in the care for PWS.  Also the advisory group was consulted and a focus group meeting was organized. The results of the survey and the focus group meeting have led to the following questions, to be answered in the guideline:

  1. When should therapy begin for young children who start to stutter?
  2. What are the validity and the reliability of the diagnostic instruments for stuttering?
  3. What is the effect of stuttering therapy in preschool children?
  4. What is the effect of stuttering therapy in school-aged children?
  5. What is the effect of stuttering therapy in adolescents and adults?
  6. When should an SLT consider referral of the patient to another specialist?
  7. How to organize maintenance/follow-up therapy?

Grading the scientific evidence

When starting the Dutch Clinical Guideline (Pertijs et al, 2014) we decided not just to update pre-existing ones (as these from USA, GB and Canada) because all were over seven years old. Instead, we started over again, which enabled us to introduce the recent technique Grading of Recommendations Assessment Development and Evaluation (GRADE) Working Group approach (Guyatt et al., 2008). This method enables to utilize different sources of knowledge according to their intrinsic scientific strength. GRADE classifies the quality of evidence as high, moderate, low or very low. The quality of evidence reflects the extent of our confidence that the estimates of the effect of therapy are correct.  If the evidence is evaluated “high” then we are very confident that the true effect lies close to that of the estimate of the effect. If the evidence is evaluated ‘low” our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect.  Various sources (publications, commonly adopted best clinical practice etc.) will be awarded with a specific level (ranging from very low to high).  GRADE however allows the quality of evidence to be upgraded or downgraded, depending on the details of the design and execution of the studies. For example, consideration is given to the magnitude of the effect, the risk of bias, study limitations and consistency of the results. Based on that, the quality of the evidence can be upgraded or downgraded in its ultimate ranking.   (For more information about search strategy , inclusion and exclusion criteria e.g. , see original guideline document p142-144 on  http://nvlf.logopedie.nl/site/inhoudelijke_richtlijnen, or www.nedverstottertherapie.nl)

From Evidence to recommendation

Besides the quality of the evidence other aspects are also taken into account. E.g.: concerning diagnostic instruments, we examined the validity and reliability of the instruments. But we also discussed issues like: What are the benefits of working with this instrument, what are the disadvantages, what are the costs, what is the impact on the PWS?  The working group weighed all such issues and the conclusion is reflected in the strength of the recommendation.

An example of a weak recommendation is the recommendation on therapy in school-aged children.  The research on the effect of stuttering therapy in school-aged children is limited and the quality of the evidence was rated as low. Our recommendation therefore is weak and not very specific:

“The treatment of stuttering children between the ages of 6 and 13 years should preferably be based on a treatment plan that contains all elements of the International Classification of Functioning Disability and Health (ICF) model. Therapy should focus on stuttering behaviours, emotions and/or cognitions, and should depend upon assessment findings. The parents and the child who stutters should consent to the treatment plan.”

When a recommendation is weak, clinicians and clients need to devote more time to the process of shared decision-making by which they ensure that the informed choice reflects individual values and preferences.

An example of a stronger recommendation is the recommendation on therapy to children under 6 years of age. Here we recommend to either use the Lidcombe Program (Onslow, Packman & Harrison, 2003) or treatment based on the Demands and Capacities Model (DCM) (Starkweather & Gottwald, 1990).  The effect of the Lidcombe Program is found to be large and the quality of the evidence was rated as moderate. The effect of treatment based on the DCM model has shown similar results.

“Discuss with the parents of children who stutter up to six years of age the benefits of stuttering treatment versus no treatment option (reduction of percentage stuttered syllables and stuttering severity).  Explain the differences between the ‘Lidcombe program’ and treatment based on the ‘Demands and Capacities Model’.  Come to a shared decision with the parents which of the two approaches is preferred.”

The importance of the evidence based guideline for SLTs

The current guideline has been written to ensure broad acceptance within the field, and in the Dutch implementation, clinicians should know how to use these guidelines. Therefore basic education about how to interpret and use the guideline will be increased. In this sense, basic education of SLTs will also be increased, enabling easier cooperation within the profession and easier communication with society at large. Guidelines don’t represent a rule box, but rather a tool box. SLTs should learn to take decisions based upon the recommendations from this guideline. SLTs may deviate from any recommendation based on their own clinical experience and responsibility, but they must discuss that with the client (shared decision making) and they must document such a possible different choice in their case reports.

The importance of the evidence based guideline for PWS

Clients are using clinical guidelines increasingly to understand and to make decisions regarding their health (Loudon et al., 2014). Clients do need information that fits their needs to make more informed health choices. Productive interactions between the (informed) patient and the health care professional have been shown as a key component of good care. Clinical guidelines that increase self-management will help the client to become better at his problem-solving skills, to become less dependent of a healthcare professional, to participate more in society, getting a higher quality of life. Furthermore, the informed client will be more motivated in following therapy, more satisfied, loyal and the interaction is more productive (Légare et al., 2011).

The above mentioned evidence-based clinical guideline for stuttering has been rewritten in a second version especially for PWS. A specific study one of us performed to that end showed that this client’s version could stimulate the understanding of PWS, which resulted in an increase in self-management and an improved quality of life (Ormondt, 2015).

International Cooperation

Within the Netherlands we have experienced a burst of new activities and better understanding in and within various groups partaking in the process of guideline development and implementation. As mentioned above, the Dutch guideline is the most recent one and the only one based on generally acceptable GRADE criteria. We, therefore, have been asked to make this guideline available in English, and that process is almost finished. Of course specific (national) factors have to be taken into account, such as organization of health care and basic financial means, which do differ between various countries in the world. Still, by aiming for, writing and implementing such guidelines, well informed clinical practice will reach more and more clients for the common good.

We propose that to be a worldwide action, supervised by the IFA, and followed carefully by the ISA.

References

Guyatt, G.H., Oxman, A.D., Gunn, E.V., Kunz, R., Falck-Ytter, Y. & Schünemann, H.J.(2008). GRADE: what is “quality of evidence” and why is it important to clinicians? British Medical Journal, 336, 995-998.

Légaré, A.B., Weijden, T. van der, Pakenham, C., Burgers, J., Légaré, J., St-Jacques, S., Gagnon, S. (2011). Patient and public involvement in clinical practice guidelines: A knowledge synthesis of existing programs. Medical Decision Making, 31, E45-E74.

Loudon, K., Santesso, N., Callaghan, M., Thornton, J., Harbour, J., Graham, K., Harbour, R., Kunnama, I., Liira, H., McFarlane, E., Ritchie, K., Treweek, S. (2014). Patient and public attitudes to and awareness of clinical practice guidelines: a systematic review with thematic and narrative syntheses. BMC Health Services Research, 14, 321-334.

Onslow, M. Packman, A. Harrisson, E. (2003). The Lidcombe Program of Early Stuttering Intervention: A Clinicians’s Guide. Austin. Texaz: Pro-ed.

Ormondt, J van. (2015). Zelf-management bij stotteren door patiënteninformatie, Bachelor thesis, Hanze University for Applied Sciences, Groningen.

Pertijs, M.A.J., Oonk, L.C., Beer, de J.J.A., Bunschoten, E.M., Bast, E.J.E.G., Ormondt, van J., Rosenbrand, C.J.G.M., Bezemer, M., Wijngaarden, van L.J., Kalter, E.J., Veenendaal, van H. (2014). Evidence-based Richtlijn Stotteren bij kinderen, adolescenten en volwassenen.  Nederlandse Vereniging voor Logopedie en Foniatrie, Woerden.

Starkweather, C.W., Gottwald S.R. (1990). The demands and capacities model II: Clinical applications. Journal of Fluency Disorders 15(3); 143-157

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Comments

Evidence-based Clinical Guidelines for Stuttering — 36 Comments

  1. I’m constantly frustrated by the attitude of Speech Pathologists who constantly ignore strategies and techniques that are working in the real world because they may not be “evidence-based”. What consideration do you think should be given to “practice-based” evidence; techniques which may not have been the subject of formal research but are changing lives in the real world? Are they considerations under your “The Patient’s Perspective” element? I know many people who have been “cured” of stuttering by changing their self-limiting beliefs and chronic social anxiety using a variety of strategies. How would you suggest one might overcome the attitude by some that their research is the only truth?
    Thank you, Geoff

    • Hi Geoff! I won’t presume to answer on behalf of the authors but I did want to say something about the comparison of ‘evidence-based’ vs other techniques. I wouldn’t say this is an attitude, it is more of a well established practice in medicine to be able to accurately reproduce the same effect given a set of circumstances and measurements. That doesn’t mean that anything that has not been through such a process isn’t an effective ‘method’, if you like, but without measurement it is difficult to show how reproducible the results are.

      • Thank you Bruce for your response. I’m reminded of the quote:

        Not everything that can be counted counts, and not everything that counts can be counted – Albert Einstein

        I do have an issue when one of the main measures of success used by speech pathologists is “stuttered syllables per minute” which has an obvious focus on fluency which encourages a PWS to focus on trying to be fluent, trying not to stutter which is so counter-productive!

        • Meten is weten, as we say it in Dutch. In English (measuring is knowing) it doesn’t sound that crispy, I’m afraid, but it may be clear enough. But we have to choose the right measure, indeed. And many a good study are using other measures, like e.g. Quality of Life next to the %SS, the latter being probably easier to measure. But does that necessarily imply that the therapy is intended only to improve fluency? From what I see in the Netherlands, I don’t think so; the usage of %SS may then be more a surrogate (but useful) parameter for a greater aim.
          Actually, in Medicine that is quite common. One may take an anti hypertensive drug; final aim is to prolong healthy life, but in studies that end point is quite difficult to measure. Rather, the effect on blood pressure (of which we know from previous studies the correlation with healthy life) is taken as a surrogate parameter.
          I do hope that you see my point, and thank you for putting this forward.

          • Bert, Are %SS and Quality of Life correlated? I’ve seen no evidence to suggest this, and know many people whose personal experience would also refute it.

            • Mark, I presume. No I haven’t seen that evidence as well, and I do know many individual PWS (myself included) where the correlation (whenever present) may be weak. That’s why good studies include Quality of Life as an important measure indeed.
              In answering Geoff, though, I only said that (even if %SS is one of the parameters of many studies), the Dutch SLT’s I know don’t focus on reducing that measure – although it very well may be a (not unwelcome) result from therapy.
              Thank you for giving me the opportunity to clarify this paradoxical issue.

    • Hi Geoff,
      I am very glad you brought up this issue. The guideline is based on three essential and equal elements: the patients perspective, clinical expertise and scientific evidence. The scientific evidence for what works and what doesn’t work is limited. Therefore shared decision making plays a crucial role in many of the recommendations.
      However: when we have evidence for the positive effect of a certain therapeutic approach, we should recommend using this approach. For example we recommend to use the Lidcombe Program or the Demands and Capacities Model approach, as both proved to be equally effective. We give recommendations for when to start therapy with young children and when to wait: therapists should make their decisions about these issues based on the available evidence.
      Regarding practice based evidence: I would like to invite everybody who has a technique or a therapeutic approach that works for his or her clients to write case reports (or preferentially, studies on larger numbers)and share this practice based evidence with each other. This way we can build up the evidence ‘bottom-up. In fact,‘what works’ databases already exist for speech and language disorders, but not for stuttering as far as I know.
      Wouldn’t that be a great project to start for fluency disorders?
      Thank you again for your reaction

      • Hello Leonoor. I love your reply thank you. Building evidence “bottom-up” is inspirational and in my opinion is the way forward for improved treatments and outcomes for PWS.

        • Yes indeed, Geoff,
          Building up evidence ‘bottom-up’, building up evidence anyhow, that is only way to improve treatment – for PWS and in all other problems as well.
          If I may comment on some other points jou raised: it is not the attitude of SLP’s you seem to blame in your first mail. Firstly, PWS have been amply represented in the process of writing this guideline, both within the working group proper, but also in the focus group, giving the questions and reading the answers. But secondly and even more important: it is how the GRADE procedure is working. All recent clinical guidelines are being built that way: evidence may come up in different flavours, be it commonly shared clinical experience, case reports, studies on larger groups, meta-analyses etc. All these various types of evidence will get a different ranking order – which may get an up- or downgrading depending on scrutinous analyses of the methods and the data.
          During the discussion of this guideline at the IFA congress in Lisbon the concern has been expressed that this guideline might rule out given therapies which may have not been described properly, but which seemed to work in their own practice. Firstly, it is a tool box rather than a rule box (as quoted by Joe Klein below), but secondly Nan Bernstein Ratner commented rightly: please write that, publish it, you won’t keep your experience for yourself, won’t you?
          So, please do write your experience in a helpful way for others, all of you.

  2. Hi. Thanks for sharing the valuable work you are doing in the Netherlands!! Grading the scientific evidence for assessment/treatment effectiveness is a great idea. Best luck in your guideline development and implementation. I’m looking forward to learning more about your work.

  3. Thank you for this interesting article and for performing research in this area in order to produce evidence-based guidelines for stuttering. I am sure this valuable tool will benefit many professionals and clients.
    One of your guidelines is that if a child begins to stutter before the age of four years, he or she should begin therapy before the age of five years. I was wondering if there are any disadvantages to starting earlier, aside from the cost. If a parent is not concerned with the monetary aspect, would you recommend beginning therapy earlier? Is it ineffective at such a young age, or is not worthwhile since some children grow out of stuttering? Also, isn’t it risky to wait until a child is almost five years old, since your research has led you to strongly recommend therapy before the age of six years, whereas you gave a weak recommendation for treatment for children between the ages of six and thirteen years?
    Thank you, C. Goldberg

    • Hello Chana, thanks for your appreciation and for your relevant questions. The recommendation to start treatment before a child who stutters becomes five years of age is only one of the eight recommendations concerning the question: “What are indications to treat children who stutter?” These eight recommendations should be reviewed together but unfortunately we were not able to describe all these recommendations in the ISAD paper. One of the other recommendations about indications to treat CWS says that the SLT will monitor the child who started to stutter before four years of age, for signs of spontaneous recovery for a period of one year post onset. And other recommendations describe the criteria to start therapy at 12 months post onset (e.g. no clearly reduction of stuttering severity during the previous 3-6 months) or criteria to start therapy even if the child has been stuttering for less than 12 months (e.g. the child suffers from stuttering, parents are concerned about the child’s stuttering, the child is showing reluctance to communicate). We hope to make the guideline available in English within two months so you will be able to read all recommendations, the underlying evidence and motivation. But until that moment please feel free to write any question about this important topic.

  4. I enjoyed the paper. Guidelines are nice for people who do not have knowledge of or access to information regarding treatment theory. I as a graduate student and PWS looked to guidelines and protocols to establish a reason for participating in and providing Tx. Once, I learned of the fortifying principles embedded in various types of of treatment, I could then begin see fundamental differences in type and scope of practice. Evidence based practice is only measured according to a certain regiments philosophy. I agree that the evidence, patient and clinician are determining factors of the success of treatment. I adhere to the ABS’s (affect, cognitive, behavioral) aspects of stuttering and believe that these factors should be interwoven within a design of treatment. What factors contribute to the design of treatment? These are the same measures that will determine success. or not.

    • Yes indeed; below we are quoted having written that guidelines aren’t a rule box. Also, it isn’t a cook book having very specific recipes, but it may be seen as a frame work within which each therapist may find and make his/her own way. Thank you for bringing this up.

  5. I really like the quote, “Guidelines don’t represent a rule box, but rather a tool box.” I think that is the perfect attitude to have. Different factors will be helpful for different clients and families, but these guidelines can be a starting point for everyone. Well done.

    • A starting point for everyone indeed, that has been our aim in writing and now in translating this guideline, the most recent one and the only one written strictly under recently adopted GRADE criteria. Guidelines never are written as concrete blocks; e.g. they have to be updated every five years. In the just started process, we hope to reach that goal in a world wide effort. Of course, every guideline has to be adopted according to national circumstances, such as the availability of certain therapies, health insurance systems etc. but the science underlying the various therapeutic modalities is world wide identical, we would assume. Thanks for your support.

    • I absolutely love this quote, especially to keep in mind as I further my career as an SLP. As a second year grad student, we are bombarded with information, guidelines, rules, etc when it comes to therapy. This quote is such a great reminder to treat each client as an individual and recommend therapy services based on their individual journey. Becoming a successful SLP requires us to be flexible and accommodating for each individual person. Thanks for the insightful research paper!

      • Yes, thank you. And the main part, i.e. the whole Guideline translated in to English, still has to come.

  6. As a graduate student I really enjoyed this paper. Outlining guidelines and protocols is helpful in structuring consist therapy, especially when many of our educational resources differ.

  7. As a current graduate student in speech-language pathology, I enjoyed reading this paper and found it incredibly valuable. The work that you have done to create this guideline for the treatment and management of stuttering is informative and is something that I will consider throughout my clinical experiences. Throughout my studies, I have been learning about the role that scientific evidence, clinical expertise, and patient perspective play in order to have successful treatment. I do have a question regarding the 3 elements of evidence-based practice as it pertains to these guidelines for the treatment of a PWS: out of external scientific evidence, clinical expertise, and the patient perspective, your paper states that all 3 are important parts of the decision-making process in clinical practice, but do you think that a clinician should consider all of these as equal parts of the decision making process for the treatment and management of stuttering? Do scientific evidence and clinician experience outweigh the patient perspective in some situations? For instance, one of your recommendations that came from your research is to begin treatment for a CWS before he/she turns 5, and this recommendation has scientific evidence to back it up; however, if a family/parent/caregiver believed that his/her child will outgrow stuttering and seemed to be opposed to beginning therapy, as a clinician, should we emphasize the scientific evidence that validates that early intervention is important, and should we emphasize our own clinical expertise that shows evidence of effective treatment, or should we instead place more value on how the family perceives the situation and be okay with not intervening?

    • Thank you for this important question. May we firstly refer to the answer on Chana Goldberg’s question above: in this paper we didn’t mean to include or even to abbreviate all recommendations; rather, we meant to describe the process of writing and translating the guideline – and we only have quoted some of the recommendation as an example of what is a guideline about. But more importantly, you are wondering whether there is a hierarchy in equal parts. No, we don’t think so. SLT’s should consider patients perspective, external scientific evidence and clinical expertise as equal parts during the process of decision-making in clinical practice. SLT’s are also obliged to inform their clients to the very best of their knowledge (and SLT’s themselves do have the obligation to keep up that knowledge, e.g. by reading such guidelines and the underlying science), because no therapy will work when clients would be ‘obliged’ to follow that. A successful therapy requires mutual support. Thank you for giving the opportunity to strengthen this point.
      Bert Bast and Mark Pertijs

  8. Hi, I am a second year SLT student from England and just wanted to thank you for the article. Great information on the issues surrounding Evidence Based Practice and how Guidelines should inform practice. Thanks very much.

  9. I congratulate you all on this initiative. Clearly establishing an evidence base will improve treatment outcomes and understanding. However given that so much of the evidence base of this so called multifaceted disorder is centred on percentage syllables stuttered, which is acknowledged by researchers and clinicians to be a limited and notoriously unreliable measure of the condition, then how do you respond to the proposition that the question of evidence base in stuttering cannot be established until clear definitions of the stuttering disorder, or disorders, have been developed? For example one phenomenon of many still to be resolved are the reports of people saying they consider themselves to be fully recovered while still exhibiting dysfluencies.
    Also I am surprised that your work gave the Lidcombe programme a moderate rating for quality of evidence. There appears only one study (Jones 2008) where treatment was completed and measured against a no treatment control. There is no knowledge of how it works and it has recently been shown that parental reinforcements on which it is based do not have any effect. Also the recent extremely comprehensive Dutch study provided evidence of only similar treatment success to that of natural recovery (viz 80%). When would a treatment’s quality of evidence be regarded as low?

    • Thank you for your congratulations as well as raising these important points – which do require clarification indeed. With respect to the measured endpoints, I may refer to the 2nd answer on Geoff’s question in this thread above. In addition, in medicine it isn’t uncommon (when not sure about the precise origin of the affliction) to start with operational definitions. Working way, both in treatment and research, these lines will converge at later time. We won’t wait treating until we might know all (whenever possible indeed) won’t we? Rather, taking into account the obligations SLT’s do have (as mentioned in the answer to temcdonald1’s question above), a set well based therapeutical modalities may be given.

      The rating according to GRADE criteria of all relevant literature has been given by coauthors, specialised in this type of methodological work. I can’t reproduce it here, I’m afraid, and it would be too long as well. Possibly, the English full text (when availaible within a month or so) will help you. Also, quality of evidence is quite another thing than quality of the results according to ‘our’ wish, but we do agree about that, I presume.

      And lastly, the percentages of therapeutic recovery within the term of the study, which may resemble the percentage of spontaneous recovery within the whole population. I may raise 2 points: The percentage of spontaneous recovery within the clinical population (as it is here) after one year of onset is certainly lower – although I don’t know the precise data for precise this time point. And further, we do know the figures for spontaneous recovery within the whole population after 1, resp. 2, resp. 3 resp. 4 years after onset. To the best of our knowledge, these amount to 8, resp. 30, resp. 63, resp. 74%. So, the Dutch study on 200 children showed that early intervention resulted in a higher and faster (how can I highlight this further?) recovery as compared with the spontaneous process.

      In this study, a control group (i.e. getting no treatment) could not be included, however. Such a control isn’t ethical anymore whenever a treatment has been shown being helpful. But the historical controls, mentioned above, are clear enough, I presume. Thank you again.

      • Bert, I responded to your comment on Geoff’s question above. Secondly according to the epidemiological paper of Yairi and Ambrose (2013) natural recovery is somewhere between 80 -90%. So the higher rate of recovery you mentioned is questionable. Also is it not correct to assume a faster rate of recovery would be expected given the children were engaged in therapy and would have been aware of the encouragement to produce fluent speech? Evidence of this would be the expectation that Direct Therapy (Lidcombe) would produce faster recovery than Indirect Therapy (DCM). This is the result the study produced I believe?
        I very much appreciate the intellectual rigor you have applied to this issue. My point is that more intellectual rigor needs to be applied to the definition(s) of what it is we are building an evidence base for. Do you agree?

        • Mark, I presume. You may know that the reported extent of natural recovery in literature still is ranging, also to lower figures.
          But regarding the speed of therapeutic recovery you may be correct: in the large Dutch study quoted earlier, therapeutic recovery using the direct therapy seems to be a little faster (although statistically not significant) within the first three months, whereas that differential effect has disappeared at twelve months after treatment. Also a longer therapy doesn’t seem to give a huge increase in therapeutic effect. In that sense the data on spontaneous recovery per year, I mentioned above, may be very relevant.
          And the requirement for new intellectual strict precision? Also there you are absolutely right. In the full text of the Guideline you may read (when available within a month or so) you may read a critical appraisal of all current measures and the quest for new ones.
          Thank you again for giving the opportunity to expand; paradoxes abound in stuttering therapy as in all sciences.

  10. I really enjoyed your paper and look forward to what you have found to be helpful in school-aged children who stutter. I am a 1st year grad student currently taking a fluency course and working with a child who stutters in my elementary placement. I am finding it difficult to find resources that help guide me as to how to do treatment with a 2nd grader who says he doesn’t’ even realize he stutters and that using the overt strategies aren’t really realistic to him since it doesn’t bother him. He is a very delightful and insightful boy. I certainly do not want to ruin his self-confidence, but I do want to help him become a better communicator. However, in my limited experience I am wondering why this child is being seen if he doesn’t feel or demonstrate an adverse effect to his educational environment. I certainly don’t want to be the one to make him feel like his has a problem by negatively making him aware of his stutter. Yet, my experience in teaching in school tells me that as he ages he will become more and more influenced by what others think of him. Right now, he is in that innocent stage where he doesn’t worry about what others think about him. So, how do I help him now? I don’t want to exit him from treatment in the school because it will be hard to qualify him for treatment as he gets older. I would love your advice and comments if you have the time to do so. Thank you again and I will certainly be looking forward to more papers and sharing of information on evidence based treatments.

    • Hi Correne. If I understand you correctly in this case there are two issues that are important to you. You want him to remain a self-confident person and you want him to become a good communicator. Regarding the latter, I wonder why he is not a good communicator. In what ways does disfluency influence the communication (at a participation level)? Regarding the self-confidence I wonder what you think he needs from his environment (parents, teachers and you) to maintain his self-confidence.

  11. I am a graduate student in the U.S. currently in a Principles of Evidence-Based Practice class. I find it very valuable to read an article that relates to topics we read about in the textbook. When working with clients, is helpful to have guidelines for treatment to understand the evidence, but to also remember that these guidelines are a part of EBP and not all of EBP- we must take into consideration clinical judgements and patient values as well- which you indicated in your paper. Thank you for your important work in this field.
    Nicole

  12. Hi,
    I am a SLP grad student and am learning all I can about how to treat PWS. I was curious in your article what the evidence is about treatment. I am at a practicum with a child who stutters that shuts down at therapy and found from your article that considering the client’s age, it could be discussed with parents as to maybe postponing therapy until the child is ready and wants to benefit from therapy. Thanks for the information.

    • Hi Daylene,
      The answer to your question highly depends on the age of the child. The guideline recommends the SLT and the parents to monitor the child who started to stutter before four years of age, for signs of spontaneous recovery for a period of one year post onset and start the treatment 12 months after onset , when the severity of stuttering has not clearly reduced during the previous 3-6 months. When the child suffers from stuttering or if the parents are concerned about the child’s stuttering or if the child is showing reluctance to communicate therapy starts immediately. Monitoring is an active process, in which parents are measuring fluency development. It is definitely not the same as “wait and see”. But for children over six years of age and for children who stutter for a year or more it is quite a different story.