بررسی اثر بخشی درمان لکنت زبان

Efficacy has been defined as the extent to which a specific intervention, procedure, regimen, or service produces a beneficial result under ideally controlled conditions when administered or monitored by experts. Studies on efficacy can be divided into those that study methods of conducting treatment (i.e., treatment process research) and those that are concerned with the effects of treatments (i.e., treatment outcome research). This review covers both areas, emphasizes the former, and considers such key determinants of efficacy as measurement, treatment integrity, and design issues. A set of criteria is given and a meta-analysis of whether studies published since 1993 meet these criteria is reported (incorporating some pragmatic and ethical considerations). The review ends by considering directions that warrant further investigation in the future.

The treatment of stuttering has been described as a controversial and perplexing issue for speech language pathologists (Ingham & Riley, 1998), and recent concerns have been expressed about the absence of rigorous documentation regarding the efficacy of particular interventions Ansel, 1993, Conture, 1996, Conture & Guitar, 1993, Cordes & Ingham, 1998 and Starkweather, 1993. It has even been asserted that the state of stuttering treatment research, at least up to early 1996, was abysmal and that some leaders in the field appear to have abandoned basic scientific principles that are at the heart of any attempt to establish treatment efficacy (Cordes, 1998). Efficacy is the extent to which a specific intervention, procedure, regimen, or service produces a beneficial result under ideally controlled conditions when administered or monitored by experts (Last, 1983). In contrast, treatment effectiveness is the extent to which an intervention or treatment employed in the field does what it is intended to do for a specific population (Last, 1983). Treatment efficacy research can be characterized as an investigative tool for examining the effects of environmental variables (i.e., treatment) on organismic variables (i.e., communication behaviors). Moreover, it has been suggested that the beauty of efficacy research is its ability to address both theoretical and clinical questions simultaneously (Olswang, 1993). The dawn of a behavioral orientation to stuttering treatment in the 1960s introduced a set of principles and practices for determining treatment efficacy. This model was based primarily upon the quantification of the target of treatments, plus systematic evaluations of relevant behaviors across clinically important settings for meaningful periods of time Ingham & Andrews, 1973 and Kazdin, 1978 and did, to some extent, transcend theoretical orientations (Bloodstein, 1987). However, Schwartz (1976) published his account of “solving stuttering,” with its accompanying claim that the disorder had been treated with an 89% success rate. Reaction throughout the field was “principally directed at a glaring absence of data-based therapy evaluation” (Ingham, 1993, p. 134). Then, a second catalyst occurred in 1987, when Cooper claimed that “at least two out of every five adolescent and adult abnormally disfluent individuals are incurable stutterers” (Cooper, 1987, p. 381), which was attacked on similar grounds. It has since been suggested that the procedures recommended for evaluating the efficacy of stuttering treatment have become overwhelmingly complex, while at the same time, prevailing notions about the nature of stuttering have become increasingly biological (Ingham & Cordes, 1997). As a result, Ingham and Cordes (1997) claimed that even the most recent studies of stuttering treatment seem to have been conducted without evaluation procedures and that treatments are now being recommended with little or no empirical support. In support of this claim, Cordes (1998) reviewed 88 selected publications and reported that treatments that were most often recommended were not treatments that had been the most comprehensively researched. Systematic assessments of the efficacy of treatments utilized by a profession are “essential to the maintenance of the clinical integrity of any profession” (Curlee, 1993, p. 328). Hence, the purpose of this article is to identify some of the fundamental issues that should form the bases of evaluating treatment efficacy for stuttering. As Purser (1987) noted, evaluations of treatment efficacy involve both treatment process research (i.e., study of methods of conducting treatment) and treatment outcome research (i.e., study of the effects of treatments). This review, therefore, examines both aspects, with particular emphasis on the former, as well as the issues that need to be resolved or addressed before treatment efficacy can be assessed. Our review endeavors to provide an impartial look at studies of efficacy across treatments of stuttering that will complement recent discussions in the literature in this area (Yaruss, 1998) and in wider aspects of health care services (Kazdin & Kendall, 1998). We do not intend to promote any particular theory or to evaluate in detail programs of treatment. These objectives rule out, respectively, our consideration of Steps 2, 3, 6, and 7 of Kazdin and Kendall's (1998) list of “Steps Toward Developing Effective Treatments.” This review, instead, critically addresses: (i) measurement issues, (ii) treatment integrity, and (iii) design issues, that correspond to Kazdin and Kendall's conceptualization of dysfunction (Step 1), specification of treatment (Step 4), and tests of treatment outcome (Step 5). Yaruss (1998) provided a framework for describing the etiology and range of problems that a speaker may experience using language that other health professionals employ. However, this does not readily lend itself to assessment of the activities of professionals engaged in delivering treatments, which fall under topics (ii) and (iii).