A Framework for Discussing Outcome Measures in Stuttering

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A Framework for Discussing Outcome Measures in
Stuttering

• J. Scott Yaruss, Ph.D., CCC-SLPUniversity of
  Pittsburgh
• ASHA SID4 Leadership ConferenceTucson, AZ May
  1, 1997

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Purpose

• To present a conceptual framework for viewing
  treatment outcomes in terms of the ABC
  reactions to stuttering

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What should we measure?
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Roadblocks

• Diversity of Treatments
• Scope of Treatments
• Definitions of Success
• Diversity of Clients
• Inconsistencies in Terminology

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The International Classification of Impairments,
Disabilities, and Handicaps (ICIDH)

• Designed to describe the consequences of
  health-related problems (i.e., the individuals
  experience of diseases or disorders)

World Health Organization (1980) Original
Framework
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Definitions of I, D, and H(WHO, 1980)

• Impairment any loss or abnormality of
  psychological, physiological, or anatomical
  structure or function.
• Disability any restriction of lack of ability
  to perform an activity in the normal manner
• Handicap a disadvantage for an individual,
  resulting from an I or D, that limits...the
  fulfill-ment of a role that is normal...for that
  individual.

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ICIDH Example

• A skeletal impairment may be difficulty moving
  the arm (71.0 Mechanical impairment of... upper
  arm).
• The etiology of the impairment may be a broken
  arm, MS, or another problemthis does not matter
  for the ICIDH
• This impairment may lead to disabilities, such as
  difficulty writing (28), dressing (35) or
  reaching (53)
• The impairment and disability may then lead to
  handicaps, such as disadvantages related to
  physical independence (2), mobility (3), or
  occupation (4, e.g., curtailed occupation in
  fields that require arm mobility).

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I, D, and H for Stuttering(after Yaruss, in prep)

• Impairment Disruption in the functioning of the
  speech mechanism characterized by interruption in
  the forward flow of speech (i.e, stuttering)
• Disability Limitations in an individuals
  ability to communicate with others or to engage
  in social or work-related activities
• Handicap Disadvantages experienced by an
  individual that limit the individuals ability to
  fulfill social, occupational, or economic roles

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ICIDH and Stuttering Example

• The basic stuttering impairment is the production
  of disfluencies (37.0 Impairment of speech
  fluency)
• There are many theories re the etiology of this
  impairment, it seems safe to say that it involves
  multiple factors
• This impairment may lead to disabilities, such as
  difficulty talking (21), performing at work
  (18.4) or coping with situations (14.2)
• The impairment and disability may lead to
  handicaps, such as disadvantages related to
  occupation (4.2),social participation (5.1),
  or economic well-being (6.3)

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Confusion regardingthe ICIDH andStuttering

• Previous definitions of I, D, and H in stuttering
  have equated impairment with etiology and
  disability with handicap, so they were not
  consistent with the WHOs definitions
• The link between the stuttering impairment and
  resulting disabilities is not as direct as with
  many physical impairments and disabilities

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Mediating DisabilityThe ABCs of Stuttering

• The link between I and D is mediated by the
  individuals reactions to stuttering
• Affective Feelings, attitudes, emotions
• Behavioral Avoidance, tension, struggle
• Cognitive thought-processes, self-evaluation

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A Conceptual Framework for Discussing Treatment
Outcomes in Stuttering(after Yaruss, in prep)
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A Conceptual Framework for Discussing Treatment
Outcomes in Stuttering(after Yaruss, in prep)
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A Conceptual Framework for Discussing Treatment
Outcomes in Stuttering(after Yaruss, in prep)
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A Conceptual Framework for Discussing Treatment
Outcomes in Stuttering(after Yaruss, in prep)
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A Conceptual Framework for Discussing Treatment
Outcomes in Stuttering(after Yaruss, in prep)
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Applying the Framework to Treatment Outcomes
Research

• Helping to answering the question,What should we
  measure?
• Two approaches to measuringtreatment outcomes
• Documenting that a specific treatment program
  accomplishes the specific goals it sets
• Establishing criteria for success across the
  entire field and testing all programs against
  that criterion

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Assessing Outcomesfor Specific Treatments

• Every treatment program shoulddocument whether
  or not it achieves its goals
• Describe, in detail, the nature of the program
• Define success clearly
• Operationalize clinical decision-making
• Measure outcomes (before, during, after
  treatment)
• Report changes objectively (good and bad)

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Assessing Outcomes forSpecific Treatment Programs

• Level of measurement level of treatment

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Level of measurement level of treatment
Level of measurement level of treatment
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Assessing OutcomesAcross the Field

• Need to reach an agreementabout appropriate
  level of measurement
• Option 1 Restrict assessment to speech (i.e.
  impairment-level) measures, since stuttering is a
  speech event (Joy Armson will discuss this)
• Option 2 Assess at several different levels
• Probably not etiologytoo much disagreement
• Probably not handicapout of our realm

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A Proposal for Measuring the Outcome of
Stuttering Treatment

• Three Realms of Measurement
• Impairment speech fluency
• Reactions affective, behavioral, cognitive
  responses
• Disability ability to perform tasks (functional
  outcome)
• Rationale
• Allows different opinions about what is most
  important (including features that are under the
  surface)
• Recognizes that the most successful client is one
  who can function better in society (regardless of
  type of tx)

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Tests and Measures ofImpairment and Reactions

• Impairment speech-level measures
• Frequency, Duration, Type, Severity of Disfluency
• Speech Naturalness, Speaking Rate
• Reactions ABCs
• Affective (e.g., Speech attitudes ? S-24, ICA,
  Self-Ratings)
• Behavioral (e.g., Avoidance of speaking
  situations, tension, struggle ? Speech Situation
  Checklist, ICA, SESAS)
• Cognitive (e.g., Locus of control, thoughts about
  speaking abilities ? ICA, LCB/LOC, SESAS)

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Assessing Functional Outcomes

• Assesses ability to communicate in real-life
  setting
• One model is the ASHA FACS
• Scores communication independence in several
  realms
• social communication communication of basic
  needs reading, writing, and number concepts
  daily planning
• Uses 7-point scale (does...does with
  assistance...does not)
• In stuttering, we could assess clients ability
  to
• verbally communicate (disability in talking)
• function at work (disability in work performance)
• function in social situations (situation coping
  disability)

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Ability to Verbally Communicate

• How often does the client do the following?
  (1never, 3sometimes, 5frequently)
• Have difficulty communicating verbal messages
• Have difficulty initiating, maintaining, or
  completing conversations (e.g., because of
  listeners reactions)
• Have difficulty speaking under time pressures
• Substitute less appropriate words to avoid
  stuttering
• Avoid introducing self, answering questions, or
  making socially appropriate talk when meeting a
  new person
• Not respond when s/he knows the answer to a
  question

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Ability to Communicate at Work

• How often does the client have difficulty with
  the following? (1never, 5frequently)
• Answering the phone / Making phone calls at work
• Interacting with superiors, co-workers, employees
• Interacting with customers, clients, colleagues
• Participating in meetings (contributing ideas,
  etc.)
• Gathering information (i.e., asking questions)
• Giving oral presentations
• Performing other work-related tasks (completing
  training, making favorable impression, etc.)

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Ability to Communicate in Speaking Situations

• How often does the client have difficulty with
  the following? (1never, 5frequently)
• Using the telephone (for a variety of purposes)
• Interacting with family/friends/children
• Interacting with strangers/groups/authority
  figures
• Making speeches to small/large groups
• Asking for directions, Asking for advice
• Ordering food at a restaurant/drive-thru

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Functional Outcomes vs.Other Outcomes Measures

• Some functional outcomes questions seem similar
  to those in existing scales of speech attitudes,
  behaviors, situations, etc.
• The focus is not on how clients feel or think
  about stuttering, but on their ability to do
  tasks
• ICA feelings and beliefs about speaking and
  situations
• SESAS thoughts (confidence) about speaking
  situations
• Functional assessment ability to do certain life
  tasks
• Instruments should be used together in evaluation

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Summary