Telehealth Treatments for Stuttering Control

In terms of efficiency, the telehealth group required a mean of 10 hours 17 minutes contact time compared to the standard group mean of 12 hours 54 minutes. This difference reached statistical significance. Post-treatment questionnaires showed that while both groups expressed similar satisfaction with their treatment outcomes, the telehealth group reported the treatment by telephone was more convenient.

These two studies provide strong support for the telehealth adapted CP for three reasons: (1) both studies reported beyond-clinic, objective speech measures supported by subjective measures, (2) outcome measures were repeated and analysed independently and (3) the same procedures produced consistent outcomes.

With improvements of modern technology, the future of telehealth is likely to be Internet-based treatment, using webcam. At present we have encouraging Phase I trial results for such a version of the CP. (Carey et al., in press). Three adolescents aged 13, 14 and 15 achieved clinically significant reductions of stuttering with a mean of 11 clinician hours. The first was stuttering in beyond-clinic speaking situations pre-treatment at 16.7 %SS and at 6 months post-treatment at 1.3 %SS, but at 12 months post-treatment retained around a 50% stuttering reduction with 8.4 %SS. The other two participants fared much better. The second participant had 21.8 %SS pre-treatment, and 2.4 %SS and 2.5 %SS at 6 months and 12 months post-treatment, respectively. The third participant had 9.2 %SS pre-treatment, and 0.4 %SS and 1.6 %SS at 6 months and 12 months post-treatment, respectively.

Stand-alone Internet treatments

Perhaps the most potentially groundbreaking telehealth development is stand-alone Internet-based treatments. These treatments are completely self-directed and require no clinician input. Some progress has been made with this style of treatment with the development of a stand-alone Internet treatment and a Phase I trial of a cognitive behaviour therapy treatment for social anxiety with stuttering clients (Helgadottir et al., 2009a, 2009b). Two adult participants were no longer diagnosed with social phobia after the treatment (see Chapter 14 for details about social phobia and its treatment) and showed clinically significant improvement on a range of psychometric and quality of life measures.

There is preliminary evidence also with two participants (Erickson et al., 2012) that the CP, or some variant of it, might be viable in this format. Outcomes were measured during everyday speaking situations pre-treatment and immediately post-treatment. Participant 1 completed the programme in around 6 weeks and 26 log-ins, and Participant 2 required only 3 weeks with 35 log-ins. Participant 1 had mean pre-treatment severity of 8.7 %SS and a post-treatment mean score of 3.6 %SS. Equivalent assessments for Participant 2 were 5.6 %SS and 2.4 %SS. Both participants reported severity and situation avoidance decreased. Although these results are as yet far from compelling, and the authors reported much work to be done to refine the website, they are at least encouraging.

Advantages and disadvantages

Advantages

Telehealth stuttering treatments can contribute to equity of stuttering health care by improving access and availability of treatments. They can obviate the distance factor that prevents access by many to clinician services, and can make expert stuttering clinicians available to clients when that otherwise may not have been possible. They have the potential to provide better outcomes by means of speech restructuring techniques being learned in an everyday environment rather than a speech clinic. Although it has yet to be proven, it would not be surprising if those procedures produced more durable treatment effects because they minimise discriminated learning of stuttering control to the speech clinic and focus greater treatment responsibility on the client rather than the clinician (Stokes and Baer, 1977). A familiar treatment environment surrounded by the client’s usual familial and cultural support might also be expected to promote durability of treatment effects (Bothe et al., 2006). Telehealth is far more convenient for the client, obviating the need for travel to and from the clinic during working hours and this may increase compliance and treatment continuity (Mashima et al., 2003). Finally, the overall cost of health care would be reduced by elimination of travel costs and a reduction of time away from work (Carey et al., 2010). Additionally, for clients treated with webcam Internet-based telehealth, the need for physical and personnel clinic infrastructure is obviated. And of course, if stand-alone Internet-based treatment becomes a reality, then no resources of any kind would be needed for clients to be successfully treated!

Adolescents are generally thought to be a challenging client group. There are many sources to document that they spend a great deal of time on the Internet and that it is an important focus of their social lives. Hence the advantages of Internet-based telehealth may pertain particularly to this age group. Here is what one of the adolescents said during the Carey et al. (in press) trial:2

Having to do it over the Internet … you can choose any time in your week that you’re able to do it, because if you have a set time when you have to see a person in their office … that can be hard on you because you have to cancel other plans for that. If you’re doing it over Skype … it makes it very flexible so … you can come in contact during the week … I just sit in any room really but right now I’m in our TV room and just on the couch with the computer in front of me.

Disadvantages

At present a major limitation of telehealth treatment is that the evidence base is constrained by the absence of treatment trials by researchers independent of the researchers who published the original trials. Rapid development of technology with technical improvements to Internet webcams seems to be outpacing the publication of clinical trials. There are randomised controlled trials data for telehealth methods that do not involve the Internet (Carey et al., 2010; Lewis et al., 2008), but only Phase I data (Carey et al., in press) for fully Internet-based methods. It is also the case that, in contrast to standard versions of child and adult treatments, nothing is known about long-term outcomes. Although, as discussed previously, there is reason to believe that these may even be better with telehealth versions, at present it is completely an assumption that telehealth versions are even as efficacious as in-clinic versions in the long term. Finally, it is yet unknown whether the clinical community will accept and successfully implement what appears to be the inevitable telehealth method of webcam treatment. It is also quite onerous to consider the ethical aspects of telehealth stuttering treatments. The method heralds a completely new set of client confidentiality and data management issues and procedures.

Conclusions and future directions

The development of telehealth stuttering treatment is an exciting era for our profession to contemplate. Although there are no independent replications, clinical trials to date have been encouraging, and there is even a possibility of stand-alone Internet treatment being viable. If the foregoing assumptions of independent trial replications, durable long-term outcomes and clinician acceptance hold true, much about how we treat stuttering could change. The benefits of telehealth intervention are seemingly irresistible, and more so if it ever proves to be the case that stand-alone Internet treatment proves to be efficacious and viable. With evidence from the first community cohort of stuttering children ascertained prior to onset suggesting that early stuttering is far more common than previously thought (Reilly et al., 2009), telehealth intervention may be particularly important to handle the health care problems it poses. With the rapid advances of Internet technology, it may even be worth contemplating an era when professional preparation methods, and standard intervention methods for children and adults, are Internet based, and in-clinic treatment becomes an unusual service delivery model.

Discussion

Ann Packman
Our group was interested in variation of responsiveness to telehealth presentation of the CP for adults. Do you have any idea about what might predict how well people respond to it compared to standard treatment?
Brenda Carey
During the randomised control trial (Carey et al., 2010), the only predictor of post-treatment stuttering severity was pre-treatment stuttering severity. Previous treatment appeared to have no influence, nor did gender or family history. The trial was randomised, so we thought that participants who did not want the telehealth treatment and preferred the clinic version, but were randomised to telehealth, would not do as well, perhaps because they were technology shy. But results showed that not to be the case. The telehealth group did just as well, in fact better with the outlying participant removed, and they evaluated the treatment a little more positively, particularly in terms of convenience.
Ann Packman
Tell us about that outlying participant.
Brenda Carey
His stuttering was extremely severe, and although he had previously participated in three intensive speech programmes, he had not responded well to those. He was compliant but speech restructuring treatment just wasn’t helpful for him.
Joseph Attanasio
Brenda could you tell us why you think that clinician-free treatment is an aspiration? And what might the risks be?
Brenda Carey
Yes, I didn’t think that would be a popular thing to say to a group of clinicians when it conceivably foreshadows being out of a job. I think if you put it in the context of stepped care it is not such an onerous prospect.3 If the simplest intervention is stand-alone Internet treatment, and it mops up the health care needs of even a few of our clients, that would be a wonderful thing. Who knows, such a treatment mode may be way more successful than that.
Sheena Reilly
Brenda, someone in our group shared with us an experience working with some adolescents who felt that using webcam actually made them much more fluent. It was a medium that they often chose, for example, if talking to a girlfriend. So our question is could webcam itself act as a discriminative stimulus for stutter-free speech, considering what you talked to us about today?
Brenda Carey
I have thought about that. Participants, particularly adolescents, are at their computers often and they do a lot of talking, socialising, even shopping around their computers. So I would not be surprised if you are correct. So, if discriminated learning of stuttering control does occur with the Internet, then that would be far less of an evil than discriminated learning occurring within a clinic. The critical point here in what you say underscores the importance of having outcome measures for Internet telehealth trials independent of the Internet.
Ann Packman
Our group was interested in the interaction that occurs during the LP when you do it with webcam. How does the child really like seeing you on webcam? Do children feel that someone is actually talking to them? How do you interact with the parent? Is it like a standard session in the clinic?
Brenda Carey
So far the trials that have been done have been on LP, delivered over the phone only, but it is true that a randomised controlled trial is underway with a collaboration between the Australian Stuttering Research Centre in Sydney and La Trobe University in Melbourne. That trial compares webcam LP with the standard, in-clinic version. The children are face to face with the clinician for at least part of the session and will look very much like a child appears during a clinic session. I have had experience with webcam treatment and I find that there is little problem with establishing the usual clinical rapport with child or parent over the Internet, particularly with image and audio quality improving with technology every year.
Joseph Attanasio
Brenda, does Speech Pathology Australia have ethical guidelines for telehealth treatment, or are there moves towards developing them? In the United States, the American Speech-Hearing Association has developed some pretty strict guidelines for telehealth.
Brenda Carey
Not yet, it is early days in Australia in terms of issues such as ethics and health fund rebates and incorporation of telehealth into public health services for stuttering.
Sheena Reilly
Just a comment before a question. In our group we had the same discussion about regulation and Marilyn Langevin tells us that one province in Canada has refused permission for telehealth to occur across provinces. Now to our question. You said with reference to stepped care that telehealth may not be for all clients who stutter. Who do you think it is not for? We had a discussion about which parents and which children this might not suit, so could you address that with particular reference to age groups.
Brenda Carey
For treating children with the LP, telehealth would not be recommended as a first treatment of choice because it does take longer in the low-tech version so far tested. Webcam trials may reveal different findings, but for now we just do not know. For now if it is easy enough for a parent to get to a clinic, then for the preschool-age group I would suggest clinic-based treatment. For adolescents and adults, the existing evidence gives a different picture. For them, telehealth treatment is looking more efficient than in-clinic treatment, so if it is cheaper and easier and takes fewer hours, why would we not recommend it for any or adolescent or adult? So I am pretty open to using it for any adolescent or adult who would prefer it. There are adults who are able to continue their normal workday by fitting in their speech therapy over lunch or at a 7.30 am appointment, or who travel to different countries and can have their sessions from there. Such treatment continuity that is possible with telehealth is a big plus.
Ann Packman
Brenda this is just a request for clarification about the different models of the telehealth delivery method: the teleconferencing suite, the telephone and webcam.
Brenda Carey
We just use a normal telephone. A mobile phone can be used, but of course it is more expensive for conducting a clinical trial. For the webcam trials I just mentioned, they are using a programme which is free and can be downloaded by anyone anywhere in the world and that requires client and clinician to have a webcam and a microphone. Conveniently, most laptops these days have both. Regarding videoconferencing, a remotely located suite was used with the Sicotte et al. (2003) trial, but with the rapid proliferation of webcam, at least for stuttering treatment, it generally seems a redundant technology. Unless, of course, there are places in the world where Internet access for various reasons is not available and a videoconferencing suite is.
Ann Packman
I think maybe in Canada, where the Sicotte et al. (2003) trial was conducted, teleconferencing suites are used.
Marilyn Langevin [From the floor]
That is true. At least in Alberta such suites exist at public health centres. But in a sense they counteract the access advantages of telehealth, because clients and their parents need to go to those suites.
Joseph Attanasio
Brenda, on the issue of efficiency, could you comment about the difference between convenience and efficiency. Do you agree that we need to be aware of the distinction when reporting treatment efficiency data?
Brenda Carey
Absolutely. In all of the studies I discussed today, with the exception of the Sicotte et al. (2003) study, there are reports of clinician contact time, which is efficiency, while other data from post-treatment questionnaires pertain to convenience, or client satisfaction. Such questionnaires typically use scales to elicit from clients information related to satisfaction: how convenient they found the treatment, how easy it was to fit into their lives, how easy was it to get to know the clinician, and so on.
Sheena Reilly
Brenda, in your experience so far, do you think parents of stuttering children behave as naturally when they are involved in a webcam treatment as they do in a clinic?
Brenda Carey
Again, since there’s no data about this, I can just give my impression from my current clinical work. Definitely, I think parents feel more relaxed with webcam, as do adults and adolescents. My feeling is that people attending a clinic, whether it is a medical centre or a dental surgery or a physiotherapy clinic, experience some disempowerment in those environments. At home they are more relaxed and I think that possibly aids what they need to learn, whether it be as parents of stuttering children or clients themselves.
Ann Packman
We had some discussion about determining the appointments, if you like to call them that. When you are doing LP or CP with webcam, did you do it on a weekly basis, as occurs with the in-clinic versions?
Brenda Carey
They were both exactly as would have occurred with in-clinic treatments. People missed appointments sometimes due to being sick or on holidays or whatever. Overall, the intention has been to follow the treatment manuals as closely as possible. In fact, in some respects it was easier to maintain treatment continuity with webcam, as I said before. Minor illness or travel that would prevent in-clinic treatment sessions would not necessarily have the same effect on webcam sessions.
Joseph Attanasio
Brenda, have you found any webcam differences with how you administer treatment between LP and CP? We were wondering because the clinician has a completely different role with the two treatments; with the former the clinician teaches the parent how to do the treatment with the child but with the latter shows the adult directly what to do.
Brenda Carey
There are differences of course. With webcam you need to work differently when you are looking at a scene of a parent and child at home and you have to model how to do the treatment and look at the parent doing it over webcam. The procedure is different to in-clinic LP. But with the CP I see no difference at all with how the treatment is presented.
Sheena Reilly
I just want to come back to Joseph’s earlier point about cautions with a possible transition to Internet-based, clinician-free treatments. Our group wanted to know whether the treatments will be just reading material, and that after reading it parents and clients simply apply the recommendations to themselves as they see fit?
Brenda Carey
Definitely not. The promise of the stand-alone Internet treatments for cognitive behaviour therapy I mentioned (Helgadottir et al., 2009a, 2009b) seems to be related to a number of important factors. One is individualisation of the treatment to the specific needs of the client based on online assessment, and the capacity of the programme to generate large numbers of treatment activities based on that assessment. ‘One size fits all’ clearly cannot happen with any kind of stuttering treatment, either Internet driven or otherwise.4
Ann Packman
Can you give us any more details about the clinical trial under way of in-clinic LP compared with webcam LP?
Brenda Carey
It is for children younger than 6 years and it is a randomised controlled non-inferiority trial.
Joseph Attanasio
Brenda you alluded to this before, but I would like a direct assessment if you could about how the webcam telehealth mode affects developing a clinician/client relationship. Is there a difference? Does it take longer?
Brenda Carey
I think as clinicians we are all anxious about this aspect of the treatment development. But I have found very little difference at all: not with parents and not with adolescent clients. I think that many clients will demand telehealth treatment in the future, and I know that many are already demanding it. I think that we need to get past an assumption that in-clinic face-to-face contact is superior to webcam face-to-face contact in terms of rapport. Let’s not forget that both modes are face-to-face. I am not sure whether that is an empirical question or whether it is self-evident. It certainly is self-evident to me based on my experience, but of course, during clinical trials, secondary outcome variables about this dimension of the treatment would probably be a good idea.

References

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1 Since the conduct of the LP trials discussed here, the use of %SS during the treatment process has been deleted from the treatment manual (Packman et al., 2011). The reasons for this change are outlined by Bridgman et al. (2011).

2 Dr Carey showed the delegates a video interview with one of the participants in the trial, and this is a transcript of the interview.

3 The stepped care model of health care is overviewed in Chapter 4, p. 49.

4 The Internet program in question (CBTPsych.com) also attempts to create the feel of a ‘real’ therapist with recordings and images of real clinicians who explain the treatment and guide clients through it. Although those who attempt to use speech restructuring treatments to control stuttering encounter a great many problems to solve, they are nonetheless finite in number and can be taken account of with stand-alone Internet treatment development.

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