Friday, June 19, 2009

D&C debate: my grain of salt


I was listening to a discussion on the demands & capacity treatment approach with Joe Klein at StutterTalk: see here. I want to add my grain of salt into the wound:

1) They rightly point out that treatment needs to be better than natural recovery, but then Joe suggests that one research showed that 90% of kids recovered which is above the natural recovery rate. We need to be careful here. Some recent research has shown a natural recovery rate of 85%, but often people use 70-80%. So one really would need to have a control group to know for certain. It is important. Imagine the real rate is 85% but you have 70% in your mind. Then in each research you will claim success!

2) I rarely hear someone talking about relapse in kids. No experienced therapist would suggest that fluency in adults immediately after therapy is indicative of long-term success. You need to look at least one year down the line. Why do we never make the same argument for kids? We seem to assume that kids do not relapse, because their brain is plastic?

3) Obviously, reducing demands on a kid will make them more fluent. But isn't an easier spelling lesson also reducing dyslexia in dyslexic kids? Less difficult spelling challenges does not reduce the underlying severity of dyslexia, but gives us the allusion of improvements. If someone tells you that you have a beer belly, you can strengthen your muscles and have no belly, but you cannot keep this up forever! Without any doubt, such a low-demand environment is not forever, and at some point in their life they will be faced again with a normal-demand environment. The key question on stuttering is whether this lower demand period helps the brain to recover better and then better deal with a normal demand world! But at the very least a part of the success might well be an illusion of improvements.

4) Joe Klein said that Franken's pilot study research has shown that Lidcombe and D&C are equally good. Actually, the right statement to make is that both approaches had similar outcomes. The study design does not actually prove that the treatment approaches are actually reducing stuttering in the long-term above natural recovery but they are saying that no-one is better than the other. She is now doing it with larger number (they are at more than 120 right now), but I spoke to her and she agreed that it is not showing whether it is successful, because there is no control group.

The key question on demands and capacity as well as on Lidcombe is whether they help the natural recovery process, and make kids better equipped to handling their sensitive brain. My intuition tells me that they might well reduce symptoms in the short term and be lasting for a few but that they do not eliminate the sensitive brain per se, and a future event can make stuttering break out again. So I would rather see them as damage control exercises rather that treatment/cures.

3 comments:

Eric said...

Hey Tom,

I think you bring up many fair points. But I take issue with one major point. You wrote, “No-one ever talks about relapse in kids…Why do we never make the same argument for kids?” We brought this very issue up during Stuttering101, episode 22, about 39 minutes in. I may not completely agree with our guest’s response, but she came on Stuttering101 knowing ahead of time that we were going to ask how Lidcombe therapy considers or looks at relapse in children.

You also write,

“The key question on demands and capacity as well as on Lidcombe is whether they help the natural recovery process, and make kids better equipped to handling their sensitive brain. My intuition tells me that they might well reduce symptoms in the short term and be lasting for a few but that they do not eliminate the sensitive brain per se, and a future event can make stuttering break out again.”

Very strong points and I agree with you that it would be nice to have long term research to back up the reported “successes” of preschool therapies. This strikes me as a particularly challenging endeavor though because of the long-term aspect of following children and families. Perhaps a country like Australia or New Zealand will be up for this challenge.

Eric said...

The previous comment was actually written by Peter (not Eric). We share a StutterTalk Google email account.

Peter Reitzes

Tom Weidig said...

>> You wrote, “No-one ever talks about relapse in kids…Why do we never make the same argument for kids?” We brought this very issue up during Stuttering101, episode 22, about 39 minutes in. I may not completely agree with our guest’s response, but she came on Stuttering101 knowing ahead of time that we were going to ask how Lidcombe therapy considers or looks at relapse in children.

I agree it was too strong. I changed it to "You rarely heard someone talking..."

I did not listen to episode 22.

>>Perhaps a country like Australia or New Zealand will be up for this challenge.

Possibly the long-term large scale study from Australia we discussed might be a candidate.