MULTIDIMETIONAL OUTCOME AND LONG-TERM EVALUATION OF NON-AVOIDANCE STUTTERUNG THERAPY

Dobrinka GEORGIEVA Department of  Logopedics, Faculty of Public Health and Sport, South-West University “Neofit Rilski”, Blagoevgrad, Bulgaria

Recived: 20.01.2015 Accepted: 25.02.2015 Original article Abstract International Classification of Functioning, Disability, and Health (ICF, WHO, 2001) is a constructive framework for quality assessment and treatment in Logopedics (Speech Language Therapy). The current research study makes an attempt to introduce this standard into logopedical practice and applied research to measure the quality of life of persons with fluency disorders, such as stuttering. The quality of life is a modern multidimensional construct that covers health-medical, psy­cho­logical, social and economic factors. Good level of communication and stabilized fluency is of key importance to improve the quality of life of persons who stutter. The purpose of the study was to show a model of assessment, treatment and evaluation of the efficacy of the non-avoidance approach in adult stuttering therapy. Methods: CharlesVan Riper’s non-avoidance approach for an intensive therapy. Participants were 15 adults who stutter with an average age 25.2 years. Results: Specific significant decreasing of the two main parameters: index of dysfluencies immediately after the intensive therapy as well as duration of disfluences in seconds. The changes in speech fluency before and after the intensive therapy as well as 3 years after this therapy were obtained regarding the duration of disfluencies and index of dysfluency. Conclusion: The present model of an intensive non-avoidance therapy format for adults with stuttering disorders was successfully applied for the Bulgarian conditions. Improved fluency is an important factor for quality of life improvement of persons with stuttering disorder. Keywords: International Classification of Func­ti­oning, Disability, and Health (ICF); fluen­cy disorders; stuttering; stuttering the­ra­py; evidence-based practice; quality of life; out­comes measures.  Introduction Research status in the relevant topic in Bulgaria According to WHO the understanding of the ICF model in respect to stuttering as a type of fluency disorder requires interdisciplinary interpretation and competence (1). The application of the ICF is a constructive framework for quality diagnostics and speech therapy of stuttering in many advanced countries in the EU, the U.S. and Australia. It is known that Yaruss and Quesal (2) adapted the ICF for the needs of Logopedics (Speech-Language Pathology or Therapy). They propose that the classification should be adopted as a framework for reporting the speech therapy efficiency in relation to stuttering. The ICF model describes how stuttering can be viewed according to the following perspectives: (i) presumed etiology, (ii) impairment in body function (observable stuttering behaviors), (iii) personal factors and affective, behavior and cognitive reactions, (iv) environmental factors, (v) activity limitations and participation restrictions. Unfortunately, in Bulgaria there are no research and science-based measurements of speech and language treatment services with the use of the ICF model. The National Scientific Fund of Bulgaria (the NSF) has funded only one highly successful research project in the professional field of Public Health and Logopedics (2009-2012, contract number DTK 02/33). It was about Evidence-Based Practice in Fluency and Voice Disorders, directed by D. Georgieva, South-West University “Neofit Rilski”. The outcomes of intensive speech therapy with people of all ages who stutter were published in peer reviewed international journals (3, 4, 5). Medical treatment, health communication, social and psychological services for people who stutter were applied to enhance the quality of life of clients from the South-western region of Bulgaria, which include the capital, Sofia. A long term goal of the study was to encourage the development of health tourism in the area, which is defined as a region of health in a number of projects under the Sixth and Seventh EU Framework Program. The stuttering outcome is a change in the client’s current and future fluency status that can be attributed to antecedent health care (6). Outcomes refer to the effects of therapy, programs or policies in individuals or popu­la­tion. Outcomes may also be defined as chan­ges in status attributed to a specific in­ter­vent­ion or therapy. Within the proposed study below, an attempt is made aiming to introduce this ICF standard practice in Logopedic and Logopedic applied research for measuring the multiple outcomes in individuals with stuttering. Relevance of scientific problems in Bulgaria and Europe The EU Statistics Classification was accepted in Bulgaria in 2008. According to the EU Statistics Classification of 1999 and its methodological handbook ISCED 97 Logopedics (Speech Language Therapy) is considered a health profession and is located in professional direction 726 physiotherapy and rehabilitation. As a new member of the EU, Bulgaria undoubtedly adheres to these rules. In July 2009, the Speech Language Therapy program at South-West University in Blagoevgrad, Bulgaria successfully completed the official procedure of accreditation and evaluation as part of the health sciences professions. This act created the required conditions for conducting significant research in the field of Speech Language Pathology following the ICF model. Some statistical data on communication, speech and language disorders in Bulgaria: 2.5% of the country’s total population, or 150 000 people, are affected by stuttering or other dysfluency type. 4% of school aged children suffer from stuttering (7). The Bulgarian healthcare system offers no logopedic treatment for adolescents and adults who stutter. In a number of international publications and world cong­resses, the country is being criticized for not offering speech therapy service to adult persons who stutter (8–11). The criticism, directed at the Bulgarian practice, enforced European standards for the provision of quality speech therapy and development of instruments for measuring the quality of life of persons with communication disorders as a whole. Bulgaria participated successfully in a network project of 65 European universities, funded by the European Social Fund entitled "Network for Tuning Standards & Quality of Educational Program for Speech Language Therapists in Europe" 2010–2013, Project number 177 075-LLp-1-2010-1-FR-EARSMUSENWA (12) and was awarded a Fulbright research grant 2013 "Evidence-Based Practice through Acoustic and Electroglottographic Characteristics Measuring in Stuttering and Voice Disorders" - the only research project in the field of speech therapy in Bulgaria won by the author of the present article (13). In the frame of those projects the new paradigm “evidence-based practice” in accordance with the ICF model was strongly recommended. The new concept for the application of the ICF classification in the field of communication disorders (in the context of this current topic: stuttering) is not known by Bulgarian speech language therapists. It is fundamental with respect to speech language pathology science and therapy in some countries of the European Union, the USA, Australia and Canada. This new paradigm refers to an approach in which the current, highly qualitative research practiceс attempt to provide data not only about the clients' satisfaction from the comprehensive speech service, but also about the clients' quality of life. In Bulgaria, in general, no systematic publications on the problem have been published, even though in the European (CPLOL) and international (IALP) speech language pathology organizations this model is specified as a standard. The medical model of stuttering seeks to reveal the causes and to provide proper therapy for the persons with this communication disorder. Published scientific studies in the U.S., Canada, Australia; England draw attention to the diagnosis of the external, visible characteristics of stuttering and puts minor emphasis on the evaluation of the experience of the person who stutters as a speaker (14–17). The social, psychological and logopedical model focuses on the inclusion of the person who stutters in the society and also emphasizes the quality of his/her life. The review of the Bulgarian literature indicated a lack of knowledge of the ICF model in the country (see Table 1). Table 1. Application of the International Classification of Functioning, Disability, and Health - ICF, WHO, (1) abroad and in Bulgaria, comparative analyses regarding the stuttering disorder studies ICF-компоненти / The ICF components САД, Австралија, Канада, Англија / The USA, Australia, Canada, England Бугарија / Bulgaria Нарушувања на телесната функција / Body function disorders Conture (18); Johnson (19); Riley (20);Yairi and Ambrose (21) Не / No Нарушувања на телесната структура / Body structure disorders Chang, Erickson, Ambrose, Hasegawa-Johnson, & Ludlow (22); Foundas, Bollich, Corey, Hurley, & Heilman (23) Не / No Индивидуално- контекстуални фактори  / Individual contextual factors Cooper (24); Manning (25); Shapiro (26); Sheehan (27); Van Riper (28); Watson (29) Не / No Контекстуални фактори на животната средина / Environment-based contextual factors Craig A, Hancock K, Tran Y, & Craig M (30); Klein & Hood (31); Brutten & Shoemaker (32); Ornstein & Manning (33); Woolf (34); Wright & Ayre (35); Ayre & Wright (36) Yaruss & Quesal (2); Yaruss (38) Georgieva, (9), K. O. St. Louis, Filatova, Coskun, Topbas,  Ozdemir, Georgieva, McCaffrey, George (37) Ограничувања во активностите и рестрикции на учество / Activity limitations and participation restrictions Некои автори од САД и Австралија сметаат дека квалитетот на животот е концепт поврзан со пелтечењето: Craig et al., (39); Klompas & Ross (40) / Some authors from the USA and Australia consider the quality of life as a concept, related to stuttering: Craig et al., (39); Klompas & Ross (40). K. O. St. Louis, Filatova,  Coskun, Topbas, Ozdemir, Georgieva, McCaffrey, George (41); Georgieva, Fibiger (3);  Georgieva (4, 5). Легенда: / Legend: Медицински модел на интерпретација на пелтечењето според  МКФ / Medical model of stuttering interpretation according to ICF    Логопедски и психолошки модел на интерпретација на пелтечењето според  МКФ / Logopedical and psychological model of stuttering interpretation according to ICF Логопедски и социjален модел на интерпретациjа на  пелтечењето според  МКФ / Logopedical and social model for stuttering interpretation according to ICF   This fact makes the scientists and especially speech language therapists recognize the need for broad-based implementation of evidence-based assessment and therapy for this complex communication disorder. The purpose of the current study was to develop an ICF model of assessment, therapy and evaluation of the efficacy of the applied treatment approach in adult stuttering cases. Present Study Methodology This research study  was  built on the ICF model (1), which is a standard for speech therapists, according to the IALP guidelines for initial education in Speech-Language Pathology and the standards for practicing the clinical Logopedic profession (42–44). Methods Charles Van Riper’s non-avoidance approach for an intensive therapy (IT) format for adults was applied (45). Full and detailed description of the study procedures were published by Georgieva and Fibiger (3), Georgieva (4) and Georgieva (5). Basic considerations The design of the therapy program was elaborated by Steen Fibiger and was based on the following considerations: ü Van Riper’s stuttering modification app­ro­ach was applied. ü The team of speech therapists consider motivation as a major element in the adult stuttering therapy (AST). A lack of mo­ti­va­tion was observed for one adult. The possib­le explanation was a reflection of dis­cou­ragement because of the ‘poor” results of the precedent treatment. ü WASSP Summary Profile was applied as a way of measuring change in feelings, thoug­hts and behaviors and planning future ma­nagement (35, 36). This profile aims to re­cord how the person who stutters per­ceives his or her stuttering at the beginning and the end of a block of speech and language therapy. WASSP is an indicator for improvement in the quality of life after the therapy period. ü The AST requires involvement of four speech language therapists. ü The official training language was Bulgarian, but all of the participants were fluent in English. Specific therapy methods for assessment (SSI-3) and treatment of stuttering in adults, as well as measurement of the effectiveness of Logopedic interventions (46) were also con­duc­ted. The application of voice acoustic analysis of the voice of adults who stutter has also been planned using computerized speech laboratory (CSL) and specific softwares as RTP (Real Time Pitch), and EGG (electroglottography), (47, 48).  To take these measures in voice disorders is not obligatory but advisable. It is intended to use these various tools in the field of Public Health - Logopedics to achieve fluent speech (for a detailed description see Table 2 below). Table 2. ICF components, providing a detailed stuttering description in the current research Преглед на МКФ-компоненти во проектот  / ICF components for project examination Препорачани специфични дијагностички алатки за евалуација на ефективноста од логопедската терапија според Yaruss, (49, 50)  / Recommended specific diagnostic tools for evaluating the effectiveness of the speech intervention on Yaruss, (49, 50) Оценка и дијагностика на нарушувањето на флуентноста / Fluency disorder assessment and diagnosis Инструмент за евалуација на степенот на тежина на пелтечењето, чиј автор е Riley, (46) / Stuttering Severity Instrument SSI-3, authored by Riley, (46) Оценка на реакциите на пелтечењето / Assessment of stuttering reactions 1.        S-24 Andrews & Cutler (51 2.        Скала за пресметување на самоувереноста на возрасни кои пелтечат при пристапување и одржување на флуентноста во различни говорни ситуации (Ornstein & Manning, 52) / Self-Efficacy Scale for Adults Who Stutter (Ornstein & Manning, 52) Истражување на самооценката на лица кои пелтечат / Research on the stutterer's self-assessment Профил за самооценка при пелтечење Write & Ayer (35, 36) / Write & Ayer Stuttering Self Rating Profile ( 35,36) Протоколи на Crove (53) / Crowe’s Protocols (53) Детална оценка на говорното искуство на лицето кое пелтечи - мерење на квалитетот на животот / Comprehensive diagnosis of the speech experience of the person who stutters - measuring the quality of life Севкупна оценка на искуството кое лицето го има од своето пелтечење - Yaruss and Quesal, (2, 54) – во процес на превод и адаптација за бугарски услови / Overall Assessment of the Speaker’s Experience of Stuttering -Yaruss and Quesal, (2, 54) – in process of translation and adaptation   for Bulgarian conditions Specific research activities The main goal of the present study was to assess therapy outcomes using a variety of stuttering measurements based on Van Riper’s intensive therapy approach. Second research was conducted to specify any changes that are adopted in different speech situations (in the stabilization phase), and to demonstrate that changes are maintained after the therapy (1, 2, and 3 years after the treatment). Measurement for adults includes determination of index of dysfluencies (ID) - the number of stuttering events divided by the number of syllables, and duration of dysfluences (DDs) - in seconds, for the three longest stuttering events. Specific stuttering measurements: Application of SSI - 3 developed by Riley (46) – (Table 2 and Table 3). Table 3. Stuttering Severity Instrument for Adults – results after the assessment before the intensive treatment Клиент / Client Пол / Gender Почетен  SSI-резултат (процент) / Initial SSI score (percentage) Почетен степен на тежина / Initial severity S1 Ж / F 27 (60%) Умерен / Moderate S2 М / M 25 (41%) Умерен / Moderate S3 М / M 37 (96%) Многу тежок / Very severe S4 М / M 46 (99%) Многу тежок / Very severe S5 М / M 46 (99%) Многу тежок / Very severe S6 Ж / F 27 (60%) Умерен / Moderate S7 М / M 25 (41%) Умерен / Moderate S8 М / M 46 (99%) Многу тежок / Very severe S9 М / M 34 (88%) Тежок / Severe S10 М / M 35 (89%) Тежок / Severe S11 Ж / F 28 (61%) Умерен / Moderate S12 М / M 31 (77%) Умерен / Moderate S13 М / M 46 (99%) Многу тежок / Very severe S14 М / M 35 (89%) Тежок / Severe S15 М / M 34 (88%) Тежок / Severe Легенда / Caption: Ж(женски); М (машки);  SSI = степен на тежина за пелтечењето / F = female; M = male; SSI = Stuttering severity instrument   Participants: Fifteen adults who stutter participated (average age was 25.2 years). All of them had experienced fluency shaping therapy prior to the current intensive stuttering modification therapy (averaging 12.6 years prior to the present study; range = 4–23 years). One participant had stuttering modification therapy (one year prior to participation in the intensive course). Inclusion criteria: To participate, adults who stutter had to (i) be older than 20 years; (ii) have taken part in a previous treatment trial, and (iii) have exhibited a range of stuttering severities that ensured the sample was representative. Data collection: Each client’s files were reviewed (assessment reports and progress reports). Three types of files were recorded during the initial assessment, at the onset of IT, and the end of the five day intensive therapy, 1, 2, and 3 years after the IT. Measurements: (i) Changes in speech fluency the 1st, 2nd and 3rd year after the intensive treatment with adult stutterers. Evaluation of stuttering severity was based on stuttering frequency during oral reading and spontaneous speaking. The data collection mentioned above consists of two fluency and affective-based measurements, which were assessed before intensive treatment and immediately after the intensive treatment, as well as 1, 2, and 3 years after the IT. Precision of measures refers to the exactness with which stuttering dysfluencies can be measured. Reliability of measures: After the IT and each of the stabilization phase sessions, a five-minute video-recorded spontaneous speech sample was obtained from each of the participants. Each speaking sample contains at least 300-400 syllables to ensure reliable results. External independent evaluation was provided by an independent clinician. He reported “measurement agreement” 95%. Validity: predictive validity (criterion validity) is a gold standard because it refers to the ability to predict future measures. At the end of the intensive adult stutterers' therapy we could accurately predict whether clients would maintain their gains. Evidence-based practice:  A good clinical practice should and must be based on evidence. The clients’WASSP profiles were analysed individually.   The study offers a quantitative measure not necessarily requiring normative comparisons regarding 2011 and 2012 – the so-called post treatment period. Statistics methods: The data obtained were calculated using the Wilcoxon signed-ranks test for hypotheses testing. Results and discussion Changes in speech fluency   Figure 1. Duration of dysfluencies in seconds at the beginning versus end of the intensive treatment, and one, two and three years after the intensive treatment for subject 4  At the beginning of the treatment DD was 3.8 seconds and immediately after IT this parameter reduced to 0.8 sec. Some changes in DD were observed over the first and second months after the IT. For this client it was difficult to maintain some of the new speech modification techniques like pull-out and cancellation. The preparatory set technique was applied successfully and stabilized by the client after 6 months of training after the IT. The 0.5sec DD increased slightly 3 years after the IT. Embarrassment, fears and anger were typically presented after the student exam session. They characterized the so-called educational disadvantages of client 4 and they are related to his poor educational achievements in that period.     Figure 2. Duration of dysfluencies in seconds at the beginning versus end of the intensive treatment, and one, two and three years after the intensive treatment for all participants (n=15), (5, 13)   The Wilcoxon signed ranks test confirmed that there was a reduction of DDs before and after intensive treatment (Z – 3. 408; p < 0.001):  §  Before IT and 1 year after IT (Z – 3. 408; p < 0.001) §  Before IT and 2 years after IT (Z – 3. 409; p < 0.001) §  Before IT and 3 years after IT (Z – 3. 408; p < 0.001). Sustained reduction in DDs was achieved (p < 0.001). There was a significant reduction in the ave­rage duration of fluency disruptions. There was   a statistically significant reduction of DDs: §  After IT and 1 year after IT: (Z – 0.692; p < 0.489) §  After IT and 2 years after IT: (Z – 0.684; p < 0.494)  After IT and 3 years after IT: (Z – 1.329; p < 0.184).   Figure 3. Dysfluency index in % at the be­gi­nning versus end of the intensive treatment, and one, two and three years after the in­ten­si­ve treatment for subject 4  Marked decreases from 38% DI before the IT to 6% after the treatment course. Two months after the IT in the stabilization phase the client manifested low level of different types of disfluences with – only 0.3% variation in DI. This means that he manifested fluent speech. There was a period of instability and variation of the DI curve where the participant reverted to dysfluent speech (movements between 0.3% and a rapid increasing to 11.5%). From the client's files it was possible to show that he reported strong frustration between the 2nd and 4th months after the IT, related to associated health problems. Subsequently, the curve demonstrated strong maintenance of the fluent speech behavior and stabilization of fluency 3 years after the IT. To summarize, the client needed a prolonged period of time to consolidate the newly established speech behavior when the totally new speech techniques were applied in this sensitive period. The overall pattern showed that in order to stabilize the new stuttering behaviors acquired during the IT, continued treatment and psychological and social support for a long period are needed. Such long term support allows stabilization to continue and helps manage relapses to the old stuttering behaviors.     Figure 4. Dysfluency Index at the beginning versus end of the intensive therapy and one, two and three years after the intensive therapy for all participants (n=15), (5, 13)  Significant changes regarding reduction of disfluency index were found before and after intensive therapy (Z – 3.408; p < 0.001). DI before and after the IT show the next results: §  Before and after the 1st year (Z – 3.411; p < 0.001) §           Before and after the 2nd year (Z – 3.408; p < 0.001) §  Before and after the 3rd year month (Z – 3.408; р < 0.001). DI after the IT and after 1, 2, 3 years post therapy show: §  After IT and after the 1st year (Z – 3.068; p < 0.002) §           After IT and after the 2nd year (Z – 3.408; p < 0.001) §  After IT and after the 3rd year month (Z – 3.202; р < 0.001). WASSP Individual case results Subject 4’s individual results and their discussions are presented in this section. The initial SSI – 3 score was 46 (99%) which reflects very severe stuttering. The WASSP profile is shown in Figure 5. The WASSP profiles strongly support the observation of changes in the individual stuttering behaviors before and after the IT as well as affective, emotional, cognitive and social changes. In the individual case of client 4 (with very severe initial stuttering) remarkable speech dysfluency changes were observed immediately after the IT concerning all eight of the parameters examined. Only one of the examinees’ WASSP profile parameters did not change after the intensive course (negative thoughts during speaking). This could be explained by the client’s inability to admit how severe his stuttering was, as well as feelings and avoidance at the beginning of the course. The changes were also impressive concerning Avoidance. The present Van Riper’s non-avoidance approach requires changes in the typical avoidance behavior through desen­si­ti­zation in different speech situations. For the expe­rienced clinician it is easy to observe dec­rease of the avoidance attitude in all 4 areas: of words (from 6 to 3); of situations (from 4 to 1); talking about stuttering with others (from 5 to 1), and admitting problems to yourself (from 7 to 1). To conclude, client 4 reported a chan­ge of progress and reduction of scores for all five subscales in WASSP. WASSP-рејтинг / WASSP rating sheet Никој / None Мн. тешко / Very severе 1 2 3 4 5 6 7 Однесувања при пелтечење / Stuttering behaviors Фреквенција на пелтечење / Frequency of stutters 1 2 Физичко водење борба при пелтечење / Physical struggle during stutters 1 2 Траење на пелтечењата / Duration of stutters 1 2 Неконтролирано пелтечење / Uncontrollable stutters 1 2 Итност/стапка на брз говор / Urgency/fast speech rate 1 2 Поврзани фацијални/телесни движења / Associated facial/body movements 1 2 Општо ниво на физичка тензија / General level of physical tension 1 2 Губење на контактот со очи / Loss of eye contact 1 2 Друго / Other 1 2 Мисли / Thoughts Негативни мисли пред зборување / Negative thoughts before speaking 1 2 Негативни мисли во текот на зборувањето / Negative thoughts during speaking 1 2 Негативни мисли по зборувањето / Negative thoughts after speaking 1 2 Чувства / Feelings Фрустрација / Frustration 1 2 Срам / Embarrassment 1 2 Страв / Fear 1 2 Лутина / Anger 1 2 Беспомошност / Helplessness 1 2 Друго / Other 1 2 Избегнување / Avoidance Брз зборови / Of words 1 2 Вон ситуација / Of situations 1 2 Не се зборува со други за пелтечењето / Of talking about stuttering with others 1 2 Непризнавање на проблемот на себеси / Of admitting your problem to yourself 1 2 Недостаток / Disadvantage Дома / At home 1 2 Друштевн / Socially 1 2 Едукациски / Educationally 1 2 На работа / At work 1 2 Забелешка: во третата колона: 1 - првата  WASSP-евалуација; 2 = втората  WASSP-евалуација (по интензивниот третман) /   Note: in the 3rd column: 1= the first WASSP evaluation; 2=second WASSP evaluation (after the intensive treatment)   Figure 5. Wright & Ayer Stuttering Self-rating Profile (WASSP) summary of the client 4 His explanatory com­ments in the last section of his profile re­vealed that he had developed realistic expec­ta­tions about stuttering out­co­mes. For client 4, the fluency shaping app­roach had little or no las­ting effect which contrasted with the results of the non-avoidance approach in the present stu­dy. The non-­avoidance stuttering modi­fi­cation app­roach is primarily a phenol­me­no­lo­gi­cal treat­ment, which is difficult to evaluate in quan­ti­tative terms. WASSP Group results The set of WASSP subscales results revealed considerable positive changes in response to participation in the therapy course for the majority of the participants. It includes behaviors, thoughts, feelings, avoidance and disadvantage scales. They reported a visible change of progress in all five subscales of the WASSP. The majority of clients were strongly motivated and reduced their degree of stuttering from the beginning of the intensive therapy. The rest of the WASSP parameters changed in positive way. Conclusion The positive changes in speech fluency before and after the intensive therapy and in the follow up period (one, two and three years after the intensive therapy) were ob­tained regarding the two essential pa­ra­me­ters: (i) duration of dysfluencies, and (ii) index of dysfluency (5, 13). Improvement in stuttering duration was observed immediately upon completing the intensive therapy. This was reflected in a statis­tically significant reduction in the number of stuttered utterances per minute. In the period of nine months stabilization phase, one year, two years and three years after the therapy these positive changes were main­tained. Although therapy was for a limited time, this stuttering non-avoidance approach intensive therapy provided the clients with new key experiences and feelings that allowed them to progress based on their own effort. Usually, Bulgarian speech therapists prefer to apply fluency shaping approach and are much more familiar with it. While the non-avoidance approach is a classic example of stuttering modification approach to stuttering therapy, it is only one variant of many stuttering modification therapies. We do not know whether these results can be generalized to other stuttering modification approaches. Perhaps simply participating in the present type of group stuttering intervention may be sufficient to bring about the positive changes of the type and magnitude that we observed (5, 13). Results from this study showed that International Classification of Functioning, Disability, and Health are a beneficial framework for quality assessment and therapy in logopedics regarding stuttering. This study introduced for the first time in Bulgarian logopedical practice stuttering modification approach and represents a good example of therapy outcomes evidence-based measurement.   Acknowledgement  This study was funded in the frame of the South-West University “N. Rilski”, Bla­goev­grad, Bulgaria research project: Evi­dence-based stuttering management and measu­rement: Outcomes for a Camperdown stuttering treat­ment (2015).   Conflict of interests Author declare that have no conflict of interests. References 1.    International Classification of Functioning, Disability, & Health. Geneva: World Health Organization. 2001. 2.    Yaruss JS, Quesal RW. Overall Assessment of the Speaker’s Experience of Stuttering (OASES): documenting multiple outcomes in stuttering treatment. J Fluency Disord 2006; 31: 90-115. 3.    Georgieva D, Fibiger S. Intensive Non-avoidance Group Therapy with Adults Stuterers: Experience from Bulgaria. Dansk Audiologopaedi (Denmark). 2010 Sept; 3: 24–30. 4.    Georgieva D. Intensive Non-Avoidance Group Therapy with Adults Stutterers: Preliminary Results. Proceeding of the International  Conference of Stuttering (Editor Giacomo Soncini), Prima edizione, 7-9 June, Roma: Omega Edizioni; 2012; 163–171. 5.    Georgieva D. Intensive Non-Avoidance Group Therapy with Adults Stutterers: Follow up Data. Proceedings from the 10th Oxford Dysfluency Conference, St. Catherine college, Oxford, UK; 2015, July (in press). 6.    Golper LA, Frattali CM. Outcomes in Speech Language Pathology. Second edition. NY: Thieme, 2013. 7.    Ivanov V. Logopedics. Sofia: Nauka i izkustvo, 1973 (in Bulgarian). 8.    Georgieva D, Goranova E. The treatment of fluency disorders: experience in Bulgaria. Presentation at the 7th Oxford Dysfluency Conference; 2005. 9.    Georgieva D. Speech situations, increasing the degree of stuttering in persons aged 13–16 – PhD thesis, Sofia University, Bulgaria; 1996. 10.  Fibiger S, Peters H, Euler H, Neumann K. Health and human services for persons who stutter and education of logopedists in East-European countries. J Fluency Disord 2008; 33: 66–71. 11.  Fibiger S, Peters H, Touzet, BB, Neumann K. Therapy for persons who stutter: Eastern Europe and Latin America. In: 5th World Congress on Fluency Disorders, 25-28th July; 2006, Dublin, Ireland. 12.  NetQues Project. Network for Tuning Standards & Quality of Educational Program for Speech Language Therapists in Europe funded by ERASMUSENWA Life Long Learning Programme [online] 2010-2013 [cited 2014]. Available from: http://www.Netques.eu/?page _id=44 13.  Georgieva D. Non-avoidance Group Therapy with Adults Stutterers: Preliminary Results. CoDAS, J of Sociedade Brasiliera de Fonoaudiologia; 2014; 26 (2): 112–120. 14.  Andrews G, Guitar B, & Howie P. Meta-analysis of stuttering treatment. J Speech Hear Disord 1980;45: 287–307. 15.  Cordes AK, Ingham RJ. editors. Treatment efficacy for stuttering: a search for empirical bases. San Diego: Singular Publ. Group; 1998, 213–242. 16.  Prins D, & Ingham R. Evidence-based treatment and stuttering – historical perspective. J  Speech Lang & Hear Res 2009; 52: 254–263. 17.  Thomas C, & Howell P. Assessing efficacy of stuttering treatment. J Fluency Disord 2001; 26: 311–333. 18.  Conture EG. Stuttering: Its nature, diagnosis, and treatment. Needham Heights, MA: Allyn and Bacon. 2001. 19.  Johnson W. Stuttering and what you can do about it. Danville, IL: Interstate; 1961. 20.  Riley GD. Stuttering severity instrument (4th edition). Austin, Texas: PRO-ED; 2009. 21.  Yairi E & Ambrose N. A longitudinal study of stuttering in children: A preliminary report. J Speech Hear Res 1992; 35: 755–760. 22.  Chang SE, Erickson KI, Ambrose NG, Hasegawa-Johnson MA & Ludlow CI. Brain anatomy differences in childhood stuttering. NeuroImage 2008; 39: 1333–1344. 23.  Foundas AL,  Bollich AM, Corey DM, Hurley, M, & Heilman, KM. Anomalous anatomy of speech-language areas in adults with persistent developmental stuttering. Neurology 2001; 57: 207–215. 24.  Cooper EB. Chronic perseverative stuttering syndrome: A harmful or helpful construct? Am J Speech Lang Path 1993; 2(3):11–15. 25.  Manning WH. Clinical decision making in fluency disorders (3rd ed). Clifton Park, New York: Delmar/Cengage Learning. 2010. 26.  Shapiro DA. Stuttering Intervention. A Collaborative Journey to Fluency Freedom (2nd ed). Austin, Texas: Pro-ed; 2011. 27.  Sheehan JG. Stuttering: Research and therapy. New York: Harper and Row; 1970. 28.  Van Riper C. The nature of stuttering (2nd ed). Englewood Cliffs, New Jersey: Prentice Hall; 1982. 29.  Watson JB. Exploring the attitudes of adults who stutter, J Com Disord 1995; 28: 143–164. 30.  Craig A, Hancock K, Tran Y, & Craig M. Anxiety levels in people who stutter: A randomized population study. J Speech Lang Hear Res 2003; 46: 1197–1206. 31.  Klein JF & Hood SB. The impact of stuttering on employment opportunities and job performance. J Fluency Disord 2004; 29(4): 255–273. 32.  Brutten GJ & Shoemaker DJ. A two-factor learning theory of stuttering. In Travis LE (Ed), Handbook of speech pathology and audiology. Englewood Cliffs, NJ: Prentice Hall; 1971: 1035–1072. 33.  Ornstein A & Manning W. Self-efficacy scaling by adult stutterers. J Com Disor 1985; 18: 313–320. 34.  Woolf  G. The assessment of stuttering as struggle, avoidance and expectancy. British J Disord Com 1967; 2: 158–171. 35.  Wright L, Ayre A. WASSP: Wright and Ayre Stuttering Self-rating Profile. Bicester: Speechmark; 2000. 36.  Ayre A, Wright L. WASSP: an international review of its clinical application. Intern J  Speech Lang Path 2009;11(1): 83–90. 37.  St Louis KO, Filatova Y, Coskun M, Topbas S, Ozdemir S, Georgieva D, McCaffrey E, George R. Public Attitudes Toward Cluttering and Stuttering in Four Countries. Chapter in book “Psychology of Stereotypes”, Nova Science Publishers, Inc,  New York, 2011; 81-115.  38. Yaruss JS. Assessing quality of life in stuttering treatment outcomes research. J  Fluency Disord 2010; 35: 190–202. 39.  Craig A, Blumgart E, & Tran Y. The impact of stuttering on the quality of life in adults who stutter. J Fluency Disord 2009; 34 (2): 61–71. 40.  Klompas M & Ross E. Life experience of people who stutter, and the perceived impact of stuttering on quality of life: Personal accounts of South African individuals. J Fluency Disord 2004; 29(4): 275–305. 41.  St. Louis KO, Filatova Y, Coskun M, Topbas S, Ozdemir S, Georgieva D, McCaffrey E, George R. Identification of cluttering and stuttering by the public in four countries. Intern J Speech-Language Pathology; 2010;12 (6): 508–519. 42.  IALP International Association of Logopedics and Phoniatrics. Guidelines for initial education in logopedics (speech/language pathology/ therapy, orthophony, etc.): Folia Phoniat Logop 1995; 47: 296–301. 43.  IALP (2010) Education Guidelines (September 1, 2009): Revised Guidelines for Initial Education in Speech-Language Pathology. Folia Phoniat Logop; 2010;62:210–216. 44.  Standing Liaison Committee of Speech and Language Therapists or Logopedists of the European Union: CPLOL, Paris, [online] 1998; [cited 2014] Available from: http://www.cplol.eu/images/Documents/educa-tion/Revised_Min_Standards _2007_la.pdf 45.  Van Riper C. The treatment of stuttering. New Jersey: Prentice-Hall; 1973. 46.  Riley G. Stuttering severity instrument for children and adults. 3rd edition. Austin: Pro-Ed; 1994. 47.  Georgieva D. Acoustic and Electroglottographic Voice Characteristics in Stuttering: Data From Two Cases. Proceedings of the 10th International Conference on Advances in Quantitative Laryngology, Voice and Speech Research, June 3-4, Cincinnati, Ohio, USA. 2013a; 83–84. 48.  Georgieva D. Acoustic and Electroglottographic Voice Characteristics in Stuttering: Group Study. Proceedings of the 10th International Conference on Advances in Quantitative Laryngology, Voice and Speech Research, June 3-4, Cincinnati, Ohio, USA; 2013b; 85–86. 49.  Yaruss JS. Measuring multiple outcomes in stuttering treatment. In: 7th Oxford Dysfluency Conference, Oxford, 2005; 5–11. 50.  Yaruss JS. Describing the consequences of disorders: Stuttering and the International Classification of Impairment, Disability, and Handicaps. J Speech Lang Hear Res 1998; 49, 249–257. 51.  Andrews G,  Cutler J. Stuttering therapy: The relation between changes in symptom level and attitudes. J Speech Hearing Disord; 1974, 34: 312–319. 52.  Ornstein A, Manning, W. Self-efficacy scaling by adult stutterers. J Com Disord 1985;18, 313–320. 53.  Crowe TA, Cooper EB. Clinician attitudes toward and knowledge of stuttering. J Com Disord 1977;10: 343–357. 54.  Yaruss JS, Quesal RW. Stuttering and the International Classification of Impairment, Disability, and Health (ICF): An update. J Com Disord 2004; 37: 35–52.