Book review: "What Stuttering Treatments are Effective?"

Title:      What Stuttering Treatments are Effective? An evidence-based review of more than 200 scientific studies

Author:   Thomas David Kehoe

Date: 2013

Publisher: E-book which can be downloaded free from: http://www.casafuturatech.com/stuttering-e-book

Length: 63 pages.

Reviewed by: Peter Louw

Mr Kehoe is an author and owner of Casa Futura Technologies which manufactures electronic anti-stuttering appliances. A while ago I had the pleasure of reading his "No Miracle Cures - A Multifactoral Guide to Stuttering Therapy", also a free and very readable e-book but no longer available on his website, and one can assume that the new work replaces "No Miracle Cures" as a reflection of what are in his opinion the most successful stuttering treatments currently available.

An independent-minded thinker about stuttering and a person who stutters himself, Mr Kehoe has a clear and concise writing style so that the not-so-knowledgeable can also follow him. As a manufacturer of anti-stuttering devices and therefore having a vested interest in such treatments he nevertheless gives due credit to other approaches. It is to be noted that he regards vocal-cord activity to be at the core of stuttering.

The term "effective treatment" needs to be defined, of course, and in this context it does not mean that the treatment will permanently cure all clients who are treated. Such a cure currently does not exist, and "effective treatment" as used in speech pathology has a more modest meaning though personally I find this use of "effective" slightly misleading. Maybe a better title would have been "What Stuttering Treatments are Best?"

'Poor quality of research'

The book starts off with a description of his methodology, followed by sections on pre-school children on the one hand and adults, teens and school-age children on the other. Under this last heading he discusses the results of i.a. stuttering modification, prolonged speech and fluency shaping, GILCU, Regulated Breathing (Passive Airflow) and other approaches. Further chapters are on altered auditory feedback (including studies on the SpeechEasy appliance) and medications such as vitamin B-1. A final section consists of reviews written by stutterers themselves on how they experienced various therapy programmes including Hollins, Van Riper's approach, ISTAR, Ross Barrett, Camperdown and others.

Mr Kehoe has based his findings on various published treatment studies, including a 2006 systematic review of 162 studies published in the American Journal of Speech-Language Pathology (AJSLP). Interestingly he quotes the AJSLP reviewers who found that the quality of stuttering treatment research was generally poor, with the average of 162 studies scoring 2.51 out of 5 trial quality criteria. The most common missed trial quality criterion was speech samples taken outside of the speech clinics. Other reviewers also noted the poor quality of stuttering treatment research.

One reason for this poor quality, says the author, is that treatment works best where various approaches are combined. With such combinations, however, it becomes very difficult to determine which approach was the most effective. For instance, if you combine fluency shaping with stress management and achieve some success, the question arises whether the fluency shaping or the stress management was the most effective.

A difficult nut to crack

A not surprising finding from the AJSLP reviewers was that the results of treatment were generally poor - stuttering, particularly that of adults and older children, remains a difficult nut to crack. With pre-school children, indirect therapy, a.k.a. parent counselling, where the parents rather than the children are trained to e.g. speak slower to and not interrupt their child, is not considered to be effective. The Lidcombe Program, however, in which parents are trained to i.a. verbally reward the child's fluent speech and to correct disfluencies by repeating the words fluently, was found to be effective, though long-term results are difficult to assess. Direct therapy for pre-schoolers, where the child is e.g. trained to speak slower, seems even more effective.

The author begins his discussion on adults, teens and school-age children by saying that in the 1930s, 1940s and 1950s stuttering therapies were based on the then-correct assumption that there was no effective treatment for stuttering. As a result, Van Riper's Stuttering Modification Therapy, in which voluntary stuttering, self-acceptance of stuttering, openness about stuttering and avoidance reduction plays a large role, was the major approach. Later studies showed, however, that this approach was of limited long-term effectiveness in reducing stuttering though it can psychologically help people to live more successfully with the disorder.

Treatments based on slower speech have been more successful. This includes "gentle onsets" (slow beginning of sentences), continuous phonation (learned by placing your fingers on your throat so as to feel the vibration of your vocal cords) and soft articulation (speaking softer and with relaxed lips, jaw and tongue). One of the drawbacks is that slower speech can be frustrating for users.

A very slight flow of air

In his discussion on Regulated Breathing (Passive Airflow), where users are taught to let slip out a very slight flow of air from their lips before speaking, and to slow beginning syllables, Kehoe writes that several studies have found that regulated breathing appears to be more effective with children than with adults, "and also relates to stuttering severity and the length of the therapy program". I am not sure how correct these views are. Another independent review has found that regulated breathing is an effective treatment; read this review.

The author concludes this section with stating that effective therapies share (apart from slower speech as mentioned) things such as i.a. relaxed, diaphragmatic breathing; relaxed vocal cords; social, emotional and cognitive (SEC) therapy; a process beginning with simple sounds and words, then progressing to longer phrases and then conversations; a process of success beginning in the speech clinic, but then expanding to application in the "real" world, and maintaining this success long-term; and stress management.

He then discusses Altered Auditory Feedback (AAF) treatment, which entails electronic appliances that relay and change your speech via a microphone back to your ears. Results with the SpeechEasy appliance were varied. In a 2009 study with the SpeechEasy it was found that about half of the effectiveness wore off over four months and that 80% of the subjects complained about "irritating background noise". A 2012 study compared the VoiceAmp appliance with Casa Futura's SmallTalk device and found that both devices reduced stuttering on average by 34%.

Thiamine - a major breakthrough?

The section on vitamin B-1 (thiamine) is particularly interesting. According to a recent promising study done by Dr Martin F Schwartz, approximately 30% of adult male stutterers benefit significantly from taking 300 mg of thiamine HCL per day, taken in three dosages of 100 mg. (Later findings suggest that the success figure could be even higher when the thiamine is supplemented by magnesium orotate - read THIS and also ALL the comments in the thread.) According to statements on his website, Mr Kehoe was at the time of writing himself on thiamine and was experiencing significant fluency. This could be a major breakthrough in stuttering therapy.

The final section containing anecdotal descriptions by stutterers of various treatments makes good reading and should in particular be studied by the providers of treatment, as it shows how people actually experience the programmes. As can be expected these descriptions vary wildly, with some people being highly critical and negative and others full of praise, depending on whether success was achieved or not. It shows once again that the success of stuttering treatment usually depends on so many things: personality, the type of stutter and of therapy, the client's perception of the therapist, the therapist's expertise, the client's motivation and the effort put in.

In conclusion, just a comment on the 'evidence-based' requirement by which the treatments were evaluated. Setting this strict requirement has the benefit of justly excluding a mass of charlatan 'treatments' offered without proof of their effectiveness; but unfortunately could also exclude honest attempts to manage stuttering where insufficient proof of effectiveness exists even though there may be a lot of anecdotal evidence of success. For instance, on stuttering websites there has been so much informal but positive feedback from people who have followed the McGuire Programme that it seems unfair to ignore the McGuire approach. This programme is known for its excellent post-workshop support, and good follow-up such as that offered by McGuire is probably one of the key ingredients of an 'effective treatment'.   

All in all I found this a very readable and well written overview of a difficult and highly controversial subject. The author has made a valiant effort to make sense of and condense a mass of often conflicting research results into a manageable format of only 63 pages. Though many will disagree with some of his conclusions they are interesting. He is also to be applauded for making this book available for free on the internet.