A recent ASHA Leader article by Peter Reitzes on treatment for preschoolers who stutter makes claims to the efficacy of some treatments that are both misleading and not evidence based – at least as far as published research is concerned. Reitzes refers readers to a study by Franken, Kielstra-Van der Schalk and Boelens (2005) that claims to have shown no difference between the results or outcome of the Lidcombe Program and a Demands and Capacities treatment approach. That study, as Bothe, Davidow, Bramlett and Ingham (2006) reported in their systematic review of research on the treatment of stuttering, is fundamentally flawed, making the results uninterpretable.
A study by Jones et al. (2005) evaluating the Lidcombe Program, did so by comparing children who stutter that were treated by Lidcombe with a control group that did not receive treatment. Another study by Yairi, Ambrose, Paden and Throneburg (1996) made it clear that preschool children (especially those who have been stuttering for less than 15 months) have a very high rate of untreated recovery. Consequently, any treatment evaluation using that age group needs to be compared with an untreated control group so as to show that its beneficial effects exceed those that would occur without treatment. In the case of the Franken et al. (2005) study there was no untreated control group. Hence, Bothe, et al. (2006) concluded that “Franken et al.’s data are difficult to interpret without a no-treatment control group to confirm that their application of either treatment was actually effective” (2005, p. 331). In fact, that is a very charitable comment because the data are not just “difficult to interpret” – they are impossible to interpret! There is nothing in this study that would show that any speech performance improvements (from Lidcombe or Demands and Capacities) exceeded those that might have occurred without treatment.
There is even more to be concerned about in the Reitzes article. He describes a presentation by Franken at the 2013 NSA conference of another study that also compared Lidcombe Program with a Demands and Capacities treatments. This study (Franken, 2013) used a larger cohort (n =199; 3-6 years) and reported findings similar to those reported by Franken et al. (2005). It was claimed that after 18 months there was no significant difference between the groups in terms of stuttering frequency and percentage of children recovered. But this study simply repeats the design error identified by Bothe et al. (2006): yet again there was no untreated control group. The importance of controlling for a natural rate of recovery is also underscored by the report that many of the study’s children may have been stuttering for between 6 and 15 months when they entered the study. It is now almost indisputable that a high rate of untreated recovery characterizes children in this bracket (Ingham & Cordes, 1999). The argument that some might raise that running an untreated control group would amount to unethically withholding treatment is not an excuse or defense. There are many alternative research designs that can offset this problem (see Kazdin, 1998). And if one is concerned about ethics in research, how can it be argued that it’s ethical to draw unwarranted conclusions about the effects of treatments for preschool children who stutter that are based on research designs that cannot support those conclusions?
The fact that the Bothe et al. (2006) review was not mentioned among the sources or references for this article is puzzling. Either Reitzes was unaware of this critique of the Franken et al. (2005) study, or for some reason chose to ignore it. Or perhaps he is unaware of the high rate of natural recovery in this population and thus did not understand the threat that that fact posed to the usefulness of the Franken and colleagues’ findings. Nonetheless, readers should not be ignorant of the deceptive message conveyed within his article.
Roger J. Ingham and Janis Costello Ingham are professors in the Department of Speech and Hearing Sciences at the University of California, Santa Barbara. Roger Ingham is an affiliate of ASHA Special Interest Group 4, Fluency and Fluency Disorders.
Bothe, A.K., Davidow, J.H., Bramlett, R.E., & Ingham, R.J. (2006). Stuttering treatment research, 1970 – 2005: I. Systematic review incorporating trial quality assessment of behavioral, cognitive, and related approaches. American Journal of Speech-Language Pathology, 15, 321-341.
Franken, M-C. (2013). Comparing a Demands and Capacities Model approach and the Lidcombe Program for preschool stuttering children: The RESTART randomized trial (Abstract). NSA Conference Presentation, Scottsdale, AZ.
Franken, M-C., Kielstra-Van der Schalk, C. J., & Boelens, H. (2005). Experimental treatment of early stuttering: A preliminary study. Journal of Fluency Disorders, 30, 189-199.
Ingham, R.J., & Cordes, A.K. (1999). On watching a discipline shoot itself in the foot: Some observations on current trends in stuttering treatment research. In N. Bernstein Ratner and E.C. Healey (Eds.), Stuttering Research and Practice: Bridging the Gap (pp. 211-230). Mahwah, New Jersey: Lawrence Erlbaum.
Jones, M., Onslow, M., Packman, A.,Williams, S., Ormond, T., Schwartz, I., et al. (2005). Randomized controlled trial of the Lidcombe Programme of early stuttering intervention [Electronic version]. British Medical Journal, 331(7518), 659.
Kazdin, A.E. (1998). Research design in clinical psychology (3rd ed). Boston MA: Allyn and Bacon.
Reitzes, P. (2014). The powered-up parent. The ASHA Leader, 19, 50-56.
Yairi, E., Ambrose, N.G., Paden, E.P., & Throneburg, R.N. (1996). Predictive factors persistence and recovery: Pathways of childhood stuttering. Journal of Communication Disorders, 29, 51-77.