اثربخشی درمان لکنت زبان در آلمان

Purpose Persons who stutter (PWS) should be referred to the most effective treatments available, locally or regionally. A prospective comparison of the effects of the most common stuttering treatments in Germany is not available. Therefore, a retrospective evaluation by clients of stuttering treatments was carried out. Method The five most common German stuttering treatments (231 single treatment cases) were rated as to their perceived effectiveness, using a structured questionnaire, by 88 PWS recruited through various sources. The participants had received between 1 and 7 treatments for stuttering. Results Two stuttering treatments (stuttering modification, fluency shaping) showed favorable and three treatments (breathing therapy, hypnosis, unspecified logopedic treatment) showed unsatisfactory effectiveness ratings. The effectiveness ratings of stuttering modification and fluency shaping did not differ significantly. The three other treatments were equally ineffective. The differences between the effective and ineffective treatments were of large effect sizes. The typical therapy biography begins in childhood with an unspecified logopedic treatment administered extensively in single and individual sessions. Available comparisons showed intensive or interval treatments to be superior to extensive treatments, and group treatments to be superior to single client treatments. Conclusion The stuttering treatment most often prescribed in Germany, namely a weekly session of individual treatment by a speech-language pathologist, usually with an assorted package of mostly unknown components, is of limited effectiveness. Better effectiveness can be expected from fluency shaping or stuttering modification approaches, preferably with an intensive time schedule and with group sessions. Educational objectives: Readers will be able to: (a) discuss the five most prevalent stuttering treatments in Germany; (b) summarize the effectiveness of these treatments; and (c) describe structural treatment components that seem to be preferable across different kinds of treatments.

Stuttering treatments are shown to have a lasting effect, both for speech outcomes and for social, emotional, and cognitive outcomes, if they contain variants of slowed speech, soft voice onset, continuous phonation, self-management, response contingencies, exercises in group sessions, and transfer into non-clinical settings (Bothe et al., 2006b and Herder et al., 2006). For preschool children, parental reinforcement for fluent speech has also shown effectiveness (Lattermann et al., 2008 and Nye et al., 2013). Pharmacological treatments have had unsatisfactory outcomes thus far (Bothe, Davidow, Bramlett, Franic, & Ingham, 2006). One of the most important findings regarding stuttering treatment effects, particularly in the study of Bothe, Davidow, Bramlett, Franic, et al. (2006) and Bothe, Davidow, Bramlett, and Ingham (2006) and most saliently in Nye et al. (2013), is that only a minority of studies fulfill methodological quality criteria of modern evidence-based research. Bothe, Davidow, Bramlett, Franic, et al. (2006) and Bothe, Davidow, Bramlett, and Ingham (2006) required as inclusion criterion that four out of five quality criteria (random assignment to groups or qualified single-subject design; blind or independent observers; both pre-treatment and post-treatment data; beyond-clinic data; controls for speech rate and naturalness) had to be fulfilled. The authors identified 39 out of 162 studies published between 1970 and 2005 that fulfilled their relatively lenient inclusion criterion. Nye et al. (2013) meta-analyzed the reports about treatment effectiveness in children and adolescents between the ages of 2 and 18 years, first excluding single-subject studies, pharmacological studies, and studies which did not report fluency measures, with a stricter methodological inclusion criterion provided by the Downs & Black, 1998Downs and Black Checklist (1998). This checklist assesses five categories of methodological quality (reporting, external validity, internal validity bias, internal validity confounding, and power) and yields an overall methodological quality rating by expert raters. With a relatively moderate and compliable cut-off (14 out of a possible 26 points) the authors could include only nine studies, from 312 citations that fulfilled the first inclusion criteria. Studies reported in German journals were not included in the above-mentioned reviews. To our knowledge there is at least one German study (Euler & Wolff von Gudenberg, 2000) which probably would have otherwise been included in the Bothe, Davidow, Bramlett, Franic, et al. (2006) and Bothe, Davidow, Bramlett, and Ingham (2006) review. An effectiveness comparison of German treatments in order to inform German prescribers is needed, but is not available. However, it is not given that the effectiveness and efficiency of treatments performed by experts under selected and often ideal circumstances, such as reported in the above-mentioned systematic reviews, compares to the effectiveness and efficiency of the same kind of treatments delivered in everyday domestic contexts (Langevin et al., 2006). Persons who stutter (PWS) or whose parents search for stuttering treatment have the right to get the most effective and evidence-based treatments recommended by professionals (Yaruss, 2001) which are locally or regionally available. Therefore, a Germany-wide retrospective questionnaire-based study on the rated effectiveness of stuttering treatment is reported in this paper. It can be expected that some of the results are generalizable to countries other than Germany, depending on how access to stuttering treatments differs between Germany and other countries where stuttering treatments are provided. Therefore, the treatment situation in Germany is described first, followed by the situation in a few selected countries. We omit the North American countries, assuming that most readers are relatively well informed about stuttering treatment in the United States and Canada. 1.1. Access to stuttering treatments in Germany, Australia, and Eastern Europe In Germany, parents who are concerned that their child might stutter most often consult a physician (pediatrician, phonatrician/pediatric audiologist, otorhinolaryngologist) who prescribes a treatment and refers the child to a logopedist (the most common Continental European occupational title for a speech-language pathologist) in a private practice or, less frequently, to a stuttering treatment center. Adult PWS who seek treatment also consult a physician in order to obtain a medical referral. The latter is required for health insurance coverage. Health insurance, which is obligatory in Germany (either public or private), covers the costs for unspecified logopedic treatments in private practices and, in most cases, partly for selected specific treatments, such as fluency shaping treatments or stuttering modification treatments (Peters & Guitar, 1991), provided in centers. Other therapies, such as breathing regulation or hypnosis-based treatments, have to be covered by the patients or parents themselves. In Australia, as an example of an English-speaking country, speech pathology services for stuttering are provided in hospitals, schools, health centers, and private practices. A medical referral is not required. Services in the public sector are free of charge and optional health insurance covers part of the costs in the private sector. Financial support is also provided by the government for a limited number of sessions with a private practitioner. As stuttering has quite a high profile in Australia, parents of preschoolers who start to stutter will often contact a speech pathologist directly for a consultation (A. Packman, personal communication, May 15, 2013). In most Eastern European countries (Fibiger, Peters, Euler, & Neumann, 2008), stuttering treatment for children is offered in kindergartens, schools, or health services and is usually free of charge. Coverage of treatment is provided by educational systems, health services, or social/health insurance. In many Eastern European countries, but not in Bulgaria and Russia, adults receive free treatment through the public health system or get full or partial reimbursement from their health insurance. Many different kinds of therapeutic approaches are reported, but fluency shaping treatment is dominant, followed by stuttering modification and a host of other treatments which are unusual elsewhere, such as “logorhythmic” therapy, phonographorhythmic therapy, “complex method,” and medication such as bronchodilatation. 1.2. The comparability of stuttering prevalence and treatment effects across languages It might be assumed that prevalence of stuttering and treatment successes differs between languages (e.g. Dworzynski & Howell, 2004). However, earlier studies about prevalence differences – as, for example, reported in Bloodstein and Bernstein Ratner (2008) – are of questionable validity and generally cannot be replicated (e.g. Proctor, Yairi, Duff, & Zhang, 2008). Despite substantial differences in phonetic complexity between languages (Dworzynski & Howell, 2004), the literature so far seems to report comparable treatment success across languages (Langevin et al., 2006 and Shenker, 2004). The conclusion of comparability across languages might turn out to be premature considering that only a few of the many existing languages have been compared. However, in the absence of contradicting data this assumption seems warranted, which justifies tentative generalizations from German to other languages. 1.3. Studies of effectiveness of stuttering treatments in Germany Reports concerning the effectiveness of stuttering treatments in Germany which fulfill a reasonable number of the methodological criteria specified in the Downs and Black Checklist (1998) are rare. A study by Lattermann et al. (2008) reports the Lidcombe treatment to produce significantly higher reduction of disfluences in preschoolers than those seen in the wait-control group. In a relatively large sample of adolescent and adult PWS (N = 238), Euler and Wolff von Gudenberg (2000) and Euler, Wolff von Gudenberg, Jung, and Neumann (2009) documented the longer-term effects of the Kassel Stuttering Therapy, a two- to three-week intensive fluency shaping approach with special biofeedback software to train smooth voice onsets and continuous phonation, as well as a one-year maintenance program which entails client monitoring of practice on the computer and two to three weekend refresher courses during a period of 12 months after the intensive course. The longer-term effects (12 months after the last refresher course, or later) were favorable both with respect to objectively assessed disfluencies – measured in four different speech tasks – and to subjective evaluations of various speech aspects, as they amounted to effects sizes of about 1.0, depending on the speech task. If relapses occurred, they did so most often within the first six months after the intensive course. Natke, Alpermann, Heil, Kuckenberg, and Zückner (2010) reported the long-term effects of the treatment of 18 clients with a stuttering modification procedure, administered as an interval treatment in group sessions with a structured treatment protocol, an explicit prescription of the speech techniques to be trained, and semiannual refreshers during the two-year period after intensive treatment. Disfluencies were measured with the use of a modified time-interval analysis ( Cordes, Ingham, Frank, & Ingham, 1992), with 3-second slices of speech categorized as “stuttered,” “fluent,” or “trained speaking pattern,” with the latter category constituting the modification. Fluency assessments, also one and two years after intensive treatment, were carried out through surprise telephone calls by an unknown person from outside the treatment context. The treatment effects sizes from before treatment to two years after intensive treatment were moderate to large, both for objective disfluency measures and for subjective measures such as attitudes toward communication and speech avoidance. A study by Kellner (1993) described the effects of a treatment according to Van Riper, but reports only subjective measures and no objective disfluency measures. Finally, Baumeister, Caspar, and Herziger (2008) published, for 40 Austrian children and adolescents, the results of a summer-camp treatment combination of fluency shaping and stuttering modification. Follow-up data, however, were reported for only two months after treatment and for only subjective measures, with a relatively large loss-to-follow-up. The German language studies with encouraging effectiveness demonstrations are not directly comparable, but three points might be worth considering: (1) the treatments were those which are reported to be the most effective in the international community, that is, the Lidcombe treatment for preschoolers and fluency shaping or stuttering modification for adults (Natke & Alpermann, 2010); (2) the treatments were intensive; and (3) the treatments were not carried out on a one-to-one basis, but were group treatments, or therapist–parent–child treatments in the case of the Lidcombe treatment. As reported above, however, the most commonly prescribed treatment for stuttering is extensive treatment in which one therapist, usually a logopedist, treats a single client, usually in a private practice and with a single session per week, and the kind of treatment is assumedly more often an eclectic composition of various treatment methods rather than an acknowledged evidence-based method executed with proper manual fidelity. 1.4. Aim of the study A retrospective evaluation of treatment by the clients themselves is currently the only available method to compare the effectiveness of stuttering treatments in Germany. Such a method is admittedly susceptible to biases – some of which, however, can be alleviated by statistical detail analyses and careful interpretation (see Sections 3 and 4). A retrospective treatment evaluation by PWS, on the other hand, has the advantage that many PWS can look back on a series of successive treatments in their biographies (Yaruss, Quesal, & Murphy, 2002) and thus are able to make within-subjects comparisons. Additionally, these persons are able to evaluate the long-term effectiveness of treatments (except for those treatments received recently). A retrospective evaluation of stuttering treatments has previously been reported by Yaruss, Quesal, Reeves, et al. (2002), who obtained respective information from 67 respondents attending a National Stuttering Association conference. A major finding was that participants who had received fluency shaping approaches were more likely to report relapse or unsatisfactory results than those who had tried other approaches, mainly stuttering modification or avoidance reduction approaches. Most data from these authors are reported descriptively (percentages of participants), usually with answer formats in grouped variable intervals. Therefore, a more detailed description is provided in Section 4 of this paper for those results which are comparable to our own ones presented below. Analysis of the order of the various treatments in the individual treatment biographies may provide an objective measure of treatment effectiveness, albeit of unknown validity, as is true for subjective evaluations. Such an ethological measure concerning what the individual does (deciding for and undergoing a particular treatment) can add validity to a purely psychological measure derived from what the individual says (evaluating a treatment in a questionnaire). An effective treatment can be expected to be more likely the last or only treatment, whereas an ineffective treatment is more likely to be followed by a further treatment, either the same or a different kind of treatment. The aims of the present study are thus the following: (1) To compare effectiveness and satisfaction ratings as well as treatment durations from PWS who have undergone stuttering treatments in the past, for those kinds of stuttering treatments that have been used mostly in Germany; (2) to investigate which aspects of the therapy, irrespective of kind of treatment (treatment schedule; individual vs. group treatment), are associated with more favorable ratings; and (3) to explore which insights into treatment effectiveness can be gained from a detailed analysis of the within-participant order of stuttering treatments, as explained in the previous paragraph.