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EBP in Stuttering Treatment for Children: The Common Factors

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EBP in Stuttering Treatment for Children: The 'Common Factors' ... 'Everybody has won and all must have prizes' - Lewis Carroll. Explaining the 'Dodo Effect' ... – PowerPoint PPT presentation

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Title: EBP in Stuttering Treatment for Children: The Common Factors


1
EBP in Stuttering Treatment for Children The
Common Factors
  • Patricia M. Zebrowski, Ph.D.
  • University of Iowa
  • USA

2
The Great Therapy Debate Different Fields, Same
Questions.
  • What therapy approach works best?
  • What is the evidence?
  • Are there different kinds of evidence?
  • If so, do they receive equal weight in treatment
    planning?
  • How does evidence translate into clinical
    practice?

3
Evidence-Based Practice
  • Evidence-based practice is the integration of the
    best research evidence with clinical expertise
    and client values.
  • best research outcomes research or
    clinically relevant research into the
    accuracy,precision, and efficacy of diagnostic
    tests and treatments
  • The Technique

4
Evidence-Based Practice
  • clinical expertise the ability to use our
    best clinical skills and past experience to
    identify delay or disorder, appropriate
    intervention, and the clients personal values
    and expectations
  • The Clinician

5
Evidence-Based Practice
  • client-values the unique preferences,
    concerns and expectations each client brings to
    the clinical experience
  • The Client

6
What Can We Learn from Psychotherapy Research?
  • Numerous studies have compared the effectiveness
    of different therapeutic approaches for
    depression, anxiety, schizophrenia, etc.
  • Many of these investigations consisted of
    meta-analyses of the efficacy of various types of
    therapy (e.g. Wampold, Mondin, Moody, Stich,
    Benson Ahn, 1997).

7
What Can We Learn from Psychotherapy Research?
  • With rare exception, research has uncovered
    little significant difference among different
    psychotherapeutic approaches.
  • This observation has been described as the dodo
    effect (e.g. Tallman Bohart, 2004).
  • Everybody has won and all must have prizes

  • - Lewis Carroll

8
Explaining the Dodo Effect
  • Different therapy approaches use dissimilar
    strategies or processes to achieve the same
    outcome
  • Research methods may not be sensitive enough to
    detect differences in therapeutic effectiveness
    among approaches OR differences are so subtle
    that they cannot be observed using conventional
    between-group designs

9
Explaining the Dodo Effect
  • Studies of treatment efficacy do not provide
    objective descriptions or operational definitions
    of therapy protocol (i.e., client-centered).
  • Studies of treatment efficacy do not provide the
    quantitative information to allow for inclusion
    in meta-analysis
  • There are common factors throughout all
    therapies that facilitate change or progress.

10
Explaining the Dodo Effect
  • It is the similarities, rather than the
    differences, between approaches that account for
    the observation that all psychotherapeutic
    approaches are, in general, effective.

11
Explaining the Dodo Effect
  • These similarities can be collapsed into four
    factors or elements that are common to all forms
    of psychotherapy
  • Technique
  • Extratherapeutic Change
  • Therapeutic Relationship
  • Hope or Expectancy

12
The Common Factors
  • Techniques factors or strategies unique to
    different therapy approaches (e.g. easy onset,
    voluntary stuttering)
  • Extratherapeutic Change characteristics of the
    client and his/her environment (e.g. temperament,
    social support)

13
The Common Factors
  • Therapeutic Relationship characteristics of the
    clinician and client (and family) that facilitate
    change and are present regardless of clinicians
    therapy orientation (i.e. technique).
    Components include shared goals, agreement on
    methods, means and tasks for treatment, and an
    emotional bond (Bordin, 1979).
  • Expectancy Hope sometimes thought of as
    placebo. Improvement that results from client
    (and clinicians?) belief that treatment will
    help.

14
Explaining the Dodo Effect
  • Further.
  • Lambert (1992) and Asay and Lambert (1999)
    reviewed the extant literature and concluded that
    these factors (separate and combined) account for
    most of the change observed in therapy.

15
Extratherapeutic Change 40
Therapeutic Relationship 30
Expectancy (Placebo) 15
Technique 15
Lambert Bergin (1994) Asay Lambert
(1999) Bernstein Ratner (2005) Franken,
Kielstra-Van der Schalk Boelens (2005)
16
TECHNIQUE
17
BEHAVIORAL APPROACHES TO STUTTERING TREATMENT
for CHILDREN
  • EMG
  • Demands/Capacities
  • Gradual Increase in Length-Complexity of
    Utterance GILCU
  • NORMAL TALKING PROCESS
  • OPERANT
  • DEMANDS/CAPACITY and LINGUISTIC AND ENVIRONMENTAL
    MANIPULATION

18
l
  • Parent-Child Interaction Therapy
  • Prolonged/smooth speech
  • Response Contingencies - Lidcombe

19
The Dodo Effect in Speech and Language
Treatment Research?
  • Robey, R. (1998). A meta-analysis of clinical
    outcomes in the treatment of aphasia. JSLHR, 41,
    172-187.
  • Law, J., Garrett, Z., Nye, C. (2004). The
    efficacy of treatment for children with
    developmental speech and language
    delay/disorder A meta-analysis. JSLHR, 47,
    924-943.

20
The Dodo Effect in Speech and Language
Treatment Research?
  • Gillam, R., Loeb, D., Friel-Patti, S., Hoffman,
    L., Brandel, J., Champlin, C., Thibodeau, L.,
    Widen, J., Bohmah, T., Clarke, W. (2005).
    Randomized comparison of language intervention
    programs. ASHA.

21
The Dodo Effect in Speech and Language
Treatment Research?
  • Treatment better than no treatment
  • On average, treatment is effective
  • Different effect sizes most likely due to client
    characteristics, age or severity of problem,
    clinician skill-level, differences in social
    validity for individual clients, and so forth.

22
The Dodo Effect in Speech and Language
Treatment Research?
  • Further research to support the conclusion that
    in general, therapy works would waste
    resources.
  • Future work should aim toward testing focused
    hypotheses (i.e., client characteristics
    clinician skill treatment approach).
  • Robey, 1998

23
The Dodo Effect in Stuttering Treatment
Research?
  • Emerging evidence that between-treatment
    comparisons yield nonsignificant findings when
    dependent variable is similar.
  • - Franken, Kielstra-Van Der Schalk
  • Boelens (2005)

24
The Dodo Effect in Stuttering Treatment
Research?
  • Herder, Howard, Nye Vanryckeghem (2006).
    Effectiveness of behavioral stuttering
    treatment A systematic review and
    meta- analysis. Contemporary Issues in
    Communication Science and Disorders, 33,
    61-73.

25
  • Results support the claim that intervention for
  • stuttering results in an overall positive
    effect.
  • Additionally, the data show that no one
    treatment approach for stuttering demonstrates
    significantly greater effects over another
    treatment approach.
  • Herder, Howard, Nye Vanryckeghem (2006).
    Effectiveness of behavioral stuttering treatment
    A systematic review and meta-analysis.
    Contemporary Issues in Communication Sciences and
    Disorders, 3, 76-81.

26
Extratherapeutic Change 40
Therapeutic Relationship 30
Expectancy (Placebo) 15
Technique 15
Lambert Bergin (1994) Asay Lambert
(1999) Bernstein Ratner (2005) Franken,
Kielstra-Van der Schalk Boelens (2005)
27
EXTRATHERAPEUTIC CHANGE
28
CHILD STRENGTHS
  • Resilience
  • Signature Strengths
  • Perceived Competence and Control
  • Phonological Abilities

29
Resilience
  • Children who are successful at regulating
    excitability and emotional reactivity exhibit
    resilience.
  • Children are described as resilient when their
    temperament and related adaptive skills (or
    personality traits) facilitate the ability to
    bounce back, or take negative experiences (e.g.
    stuttering) in stride.

30
Resilience
  • Further, these children may exhibit a more
    dominant (i.e. less timid), extraverted and
    sociable personality, and are inclined to readily
    and positively approach social situations,
    including therapy.
  • May display a relatively high degree of
    attentional focusing and risk-taking in therapy
    and in social (communication) situations.
  • Temporal substrate of rhythmicity may benefit
    from practice effects in therapy.
  • All may contribute to progress in therapy OR
    unassisted recovery.

31
Signature Strengths - Seligman,
2002
  • An important construct in Positive Psychology
  • (www.authentichappiness.org)
  • Are seen across cultures
  • Are psychological traits seen across different
    situations over time

32
Signature Strengths - Seligman,
2002
  • Can be acquired and measured
  • Contribute to adaptive coping
  • - Curiosity, interest in the world
  • - Love of learning
  • - Judgment, critical thinking,
    open- mindedness
  • - Ingenuity, practical intelligence
  • - Emotional intelligence

33
Signature Strengths - Seligman,
2002
  • - Perspective
  • - Bravery
  • - Perseverance
  • - Integrity, honesty
  • - Kindness, generosity
  • - Loving, and allowing oneself to be loved
  • - Citizenship
  • - Fairness
  • - Leadership

34
Signature Strengths - Seligman,
2002
  • - Self-control
  • - Discretion
  • - Humility
  • - Appreciation of Beauty
  • - Gratitude
  • - Optimism
  • - Sense of Purpose
  • - Forgiveness
  • - Humor
  • - Enthusiasm

35
Self-Perception of Control and Competence
  • Research in youth sport participation has shown
    that internal locus of control higher
    self-perception of competence, and vice versa
    (i.e. external locus of control).
  • Internal locus of control serves as a protective
    factor in children who exhibit high levels of
    trait anxiety or abuse/neglect.

36
Self-Perception of Control and Competence
  • Internal locus of control characterizes children
    who are motivated to engage in a particular
    activity or learning task, and maintain a high
    level of interest across time (e.g. therapy).
  • Equivocal evidence that internal locus of control
    facilitates short-term gains in stuttering
    therapy.

37
Phonological Abilities
  • Evidence suggests that children who stutter are
    more likely to exhibit (co-existing) phonological
    delay or disorder when compared to their
    nonstuttering peers (Louko, Edwards and Conture,
    1990 Paden and Yairi, 1996 Paden, Yairi and
    Ambrose, 1999 Paden, 2005).
  • AND

38
Phonological Abilities
  • Comparisons of children who recover from, and
    persist in, stuttering show that the persistent
    group are more likely to achieve poorer scores
    across a number of tests of phonological
    proficiency (Paden and Yairi, 1996 Paden, Yairi
    and Ambrose, 1999 Paden, 2005).

39
Phonological Abilities
  • Some children who stutter may exhibit
    developmental asynchronies (Watkins, Yairi and
    Ambrose, 1999 Watkins, 2005), perhaps
    contributing to a lower threshold for
    perturbation or disruption.
  • FURTHER

40
Phonological Abilities
  • Children who stutter who have age-appropriate
    phonology and speech articulation are more likely
    to experience a positive therapy outcome that is
    attained relatively quickly.
  • Young children close to onset with no
    co-occurring phonological problems are more
    likely to experience unassisted recovery.

41
THERAPEUTIC RELATIONSHIP
  • Shared goals, agreement on methods, means and
    tasks for treatment, and an emotional bond
    (Bordin, 1979).

42
  • Child and Family Education and Preparation
  • Attending to the Childs and Parents Theory of
    Change

43
Child and Family Education and Preparation
  • Coleman, D. Kaplan, M. (1990). Effects of
    pretherapy video preparation on child therapy
    outcomes. Professional Psychology Research and
    Practice, 21(3), 199-203.

44
Child and Family Education and Preparation
  • Limited understanding of clinical process OR
    mismatch between child and family expectations
    and realities encountered leads to poor
    therapeutic relationship
  • AND
  • Puts child and family at greater risk for
    dropping out of therapy

45
Child and Family Education and Preparation
  • Child and family will respond positively to
    treatment when engaged in an exploration of
    various topics, including
  • - nature of stuttering
  • - contemporary theories of etiology
  • - why children come for therapy
  • - the general structure of therapy
  • - some specifics of behavior change

46
Child and Family Education and Preparation
  • - what will be taught and why
  • - the importance of active participation
  • - self-expression
  • - trust and confidentiality
  • - child, parent and clinician roles and
    responsibilities
  • - examples of positive outcomes and how they
    were achieved

47
Attending to the Childs and Parents Theory of
Change
  • Each client and family presents the clinician
    with a new theory to learn and a new,
    client-directed intervention to suggest.
  • Research in psychotherapy has shown that what the
    client and family want from treatment, how these
    goals are accomplished , and their perception of
    improvement may be the most important factors in
    therapy.

48
Attending to the Childs and Parents Theory of
Change
  • Within the client is a theory of change waiting
    for discovery, a frame-work for intervention to
    be unfolded and accommodated for a successful
    outcome
  • (Hubble, Duncan Miller, 1999)

49
Attending to the Childs and Parents Theory of
Change
  • What ideas do you have about what needs to happen
    for improvement to occur?
  • Often people have a hunch about what is causing a
    problem, and also how they can resolve it. Do you
    have a theory of how change is going to happen
    here?
  • In what ways do you see me and this process
    helpful in attaining your goals?
  • - Hubble, Duncan Miller, 1999

50
Attending to the Childs and Parents Theory of
Change
  • How does change usually happen in your life?
  • What do you do to initiate change?
  • What have you tried to help with stuttering so
    far? Did it help? How did it help? Why didnt it
    help?
  • - Hubble, Duncan Miller, 1999

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HOPE or EXPECTANCY
56
  • Pathways Thinking
  • Agency Thinking
  • Expectancy Theory

57
Hope or Expectancy
  • Pathways thinking developing one or two ways to
    accomplish change
  • Agency thinking the ability to begin and
    persist in doing what is necessary to change.
  • Inability to experience either pathways or agency
    thinking causes stress and difficulty in coping

58
Hope or Expectancy
  • The positive emotion that stems from the ability
    to successfully engage in both pathways and
    agency thinking is the essence of hope. Hope is
    not a purely emotional phenomenon it is an
    emotional response that is rooted in cognition.
  • - Barnum, Snyder, Rapoff, Mani Thompson, 1998).

59
Hope or Expectancy
  • Expectancy Theory With hope for change comes
    expectancy that change can and will take place.
    An individuals belief that a certain treatment
    will yield a certain effect either triggers or
    correlates to that effect.
  • Expectancy Theory has long been used to explain
    the placebo effect in medicine.

60
Hope or Expectancy
  • A more positive treatment outcome is likely to
    be predicated on the clients hopefulness, but
    also on the clinicians hope and expectation that
    the client has the ability to change, and that
    they will be able to help the client bring about
    such change.
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