Recently, Speech Pathology Australia (the national speech-language pathology association of Australia) submitted a proposal to the Australian Government Department of Treasury that would require Medicare rebates be made available for children who stutter, but only if they are treated using the Lidcombe Program.
The ramifications for this action are significant. As expected, many speech-language pathologists from the U.S. and abroad do not support this action for several reasons. First, this action gravely limits the scope of treatment for stuttering. Many interventions for preschool stuttering have shown to be effective (Millard, Nicholas, & Cook, 2008; Yaruss, Coleman, & Hammer, 2006; Franken, Kielstra-Van der Schalk, & Boelens, 2005). To select any one approach and mandate its use reflects limited knowledge of the clinical process. What happens when a child receives treatment with the Lidcombe program and doesn’t make progress? Does the child have other treatment options? From this mandate, it would appear that is not the case.
Second, this mandate stifles new and innovative treatment approaches. How are new (and perhaps more effective treatment approaches) expected to emerge when only treatment with an existing evidence-base is mandated? Imagine if all infections were still treated using penicillin because it was an early treatment option. Would the government and medical associations support such a position? Perhaps a clearer question is would the lobbyists of the pharmaceutical industry allow legislators to even remotely consider the idea? Do we think less of ourselves as a profession to allow this to happen?
Third, this mandate highlights a concerning trend of what constitutes “evidence.” While certain treatments might have more data than others, that data does not always mean the treatment is more effective. Evidence-based practice includes current scientific evidence, clinician experience, and client /family values. What if the clinician is not properly trained in the treatment approach? What if the personality of the client, family, or clinician is not a good fit for one particular approach? Surely, the best “evidence” comes not from group data, but the individualized outcome of each client we serve. While group data certainly presents scientific evidence, individual outcomes present actual evidence-based practice. That type of data takes into account all aspects of the evidence-based practice triangle.
Fourth, a mandate such as this one creates obvious ethical questions. Who will train all of the speech-language pathologists to use one approach? Will there be a fee for such training? Is there an arrangement between the association, government, and trainers? These questions are not easily answered with a mandate such as this. Even if there are no financial ties, the appearance of such is obvious.
Finally, while the ramifications for stuttering treatment in Australia are apparent, this mandate has far reaching implications. After the precedent has been established, we would be naïve to think this could not happen with other disorders in all parts of the world. This is not an issue for the stuttering community of Australia to deal with. It is an issue for the speech-language-hearing community of the world to deal with.
So, where do we go from here? Here is a potential plan I would like to suggest:
1. Contact Speech Pathology Australia at policy@speechpathologyaustralia.org.au to express your concerns for this mandate. Stop the trend before it starts.
2. Advocate for reimbursement for stuttering. While the mandate outlined about is beyond concerning, the state of reimbursement for stuttering treatment in the United States can best be described as “dire.” One of our missions should be to work with insurance providers and demand that they pay for stuttering treatment. Somewhere along the way, we have allowed insurance companies to dictate that stuttering treatment should not be reimbursed. We must reverse that trend.
3. Create a consortium of professionals. This would allow a database of treatment outcomes to be collected from clinicians in the field. Not only would this help with reimbursement, but it would also allow publication of data collected from individualized treatment approaches. We are professionals, not technicians. Our clients deserve better than “follow-the-manual” based programs and protocols.
4. Educate. We need to educate our professionals and the public about stuttering. Stuttering is not merely a disruption in the flow of speech. It is much more than that.
As concerning as this mandate is, it can be a positive if we choose to act with reason, courage, and passion.
Craig E. Coleman, M.A., CCC-SLP, BCS-F
Assistant Professor, Marshall University
Coordinator, ASHA SIG-4
References
Franken, M. C. J., Kielstra-Van der Schalk, C. J., & Boelens, H. (2005). Experimental treatment of early stuttering: A preliminary study. Journal of Fluency Disorders, 30(3), 189-199.
Millard, S. K., Nicholas, A., & Cook, F. M. (2008). Is parent-child interaction therapy effective in reducing stuttering? Journal of Speech, Language, and Hearing Research, 51(3), 636-650.
Update: In order to provide both sides of the discussion, I am including the statement from Speech Pathology Australia: http://www.speechpathologyaustralia.org.au/all-latest-news/1997-budget-submission-2015-clarification
While this statement seeks to clarify that this is not an endorsement of one approach, advocating for reimbursement for only one approach certainly seems to send the opposite message. Many insurance companies will not pay for stuttering treatment here in the U.S. But responding to that by supporting a policy that would cover only one approach would be very dangerous and erroneous.
It is also important to understand that once Medicare programs establish a policy, private payers soon follow suit. It's very naive to believe this policy won't have major negative ramifications in the long run.While it may benefit some children in the short term, there is no doubt in my mind it will not benefit people who stutter or our profession in the long term.
Signatures of Support for this Post:
J Scott Yaruss, PhD, CCC-SLP, BCS-F, F-ASHA Associate Professor and Director of MA/MS Programs in Speech-Language Pathology, University of Pittsburgh Coordinator of Clinical Research, Children's Hospital of Pittsburgh of UPMC
Vivian Sisskin, M.S., CCC-SLP, BCS-F, ASHA-F Clinical Professor, University of Maryland
Charlie Osborne, MA, CCC-SLP, University of Wisconsin-Stevens Point
Joseph Donaher, Ph.D., CCC/SLP
Kathleen Scaler Scott, Ph.D., CCC-SLP, BCS-F
Corrin G. Richels, Ph.D. CCC-SLP
Farzan Irani, Ph.D. CCC-SLP
Dale F. Williams, Ph.D., CCC-SLP, BCS-F
Brooke Leiman MA, CCC-SLP
Mary Weidner, M.S., CCC-SLP
Mary Beth Mason-Baughman, PhD, CCC-SLP
Lester F. Aungst, PhD, CCC-SLP
Joel Korte, MA CFY-SLP
Peter Reitzes, MA CCC-SLP
Keely Bauer, M.S., CCC-SLP
Joseph F. Klein, Ph.D., CCC-SLP
Ashley Krieger MS CCC-SLP
Angela Farster, MA, CCC-SLP
Julia Rademacher, M.M., M.A., CCC-SLP
Sara MacIntyre, MA CCC-SLP
Andy McMillin, MA, CCC-SLP
Valerie Ostergaard, MS CCC-SLP/L
Katie Gore, MA, CCC-SLP
Stephanie Coppen, Parent
Courtney Alcott, Parent
Patricia Mason
Joan M. Ross Parent of a PWS
Kathryn Dorney MA/CCC-SLP
Jocyline Graham, M.A., CCC-SLP
Bethany Tileston, MA, CCC-SLP
Katharine Schwartz, CCC-SLP
Zeina Mvemba, MEd CF-SLP
Julie North M.S. CCC/SLP
Malayna Bailey, Student
Steve Marchant MS, CCC-SLP
Courtney Luckman, Student
Joan Duffield. Parent and teacher
Jianliang Zhang, PhD
Karen Spohn, parent
Janet Mascaro, MA CCC-SLP
Sue Shumway, Parent
Melanie Rogers, Parent of PWS
Jean Sawyer
Julie Bourke Parent
Christine Dits, M.A., CF-SLP
Tahisha Bishop
Kimberly A. McGinley, MA CCC-SLP
Valery E. Yura, M.Ed. CCC-SLP
Kathleen Helfrich-Miller, Ph.D. CCC-SLP
Nannette Crawford MA CCC-SLP
Jayme M. Lundy, MA CCC-SLP
Jennifer Coleman MS CCC-SLP
Leigh Growall MA-CCC-SLP
Karen L. Pallies, M.A., CCC-SLP
Brittany Ireland, M.S. CCC-SLP
Lynn A.C. Golightly M.S. CCC-SLP
Taz Quesinberry, M.A., CCC-SLP
Patty A. Walton, M.A, CCC-BCS-F
Timothy Flynn, M.S., CCC-SLP
Midori Rodriguez, MS, CF-SLP
Ann F. Brandt M.A., CCC-SLP
Meghan Decker, M.S. CCC-SLP
Katie Belardi, M.S., CCC-SLP
Leslie Eckenthal, MS, CCC-SLP
Brittany Fisher, M.S. CF-SLP
Jennifer Moak, M.A., CCC-SLP
Alison Oniboni, M.S., CF-SLP
E. Brooke Thevenin, student
Katrina Stewart, M.S., CF-SLP
Pei-Tzu Tsai, Ph.D., CCC-SLP
Susan Hamilton MA CCC SLP BCS-F
Jami Ellis Kukla, M.S., CCC-SLP
Claudia Kikuta, M.S., CCC-SLP
Anne Elsweiler, MA, CCC-SLP, BCS-F
Lee Caggiano, MA CCC SLP BCS-F
Bailey V. Levis, M.S., CCC-SLP
Joan Lada Butterworth, M.S., CCC-SLP, BCS-F
Jennifer Berkey, M.S., CCC-SLP
Julie Anderson, Ph.D., CCC-SLP
Erin Bass, Student
Michelle A. Jones, M.A., CCC-SLP
Heather L. Grossman, PhD, CCC-SLP, BCS-F
Beth Friedman, MA, CCC-SLP
Carin Keyes, MS CCC-SLP
Nancy Borkman, MS, CCC-SLP
Olivia Hughes, student
Dimitris Marousos
Magda Gammon
Lee Reeves
Amanda Bivens MS, CF-SLP
Kristin Holler, student
Bryan Brown MA CCC-SLP
Sherry Johnson MA, CCC-SLP
Rachel Johnson, Student
Marybeth Allen, MA-CCC-SLP
Mary Wallace, MA-CCC-SLP, BCS-F
Victoria Reynolds, CPSP
Emily Kennedy MA,CCC-SLP
Robert W. Quesal, Ph.D., CCC-SLP
Audrey Holland, Student
Karin Sorg, MS Ed., CCC-SLP
Kay Wallis, MS/CCC, BCS-F
Katie Moore, MS, CCC-SLP
Debbie Musgrave M.S. CCC-SLP
Katie Micco, MS CCC-SLP
Katerina Ntourou, PhD, CCC-SLP
Inbal K. Vellucci, M.A., CCC-SLP
Brenda Vogel, MA, CCC-SLP
Jennifer Barna, MA CCC-SLP
Frances Elvins, M.S. CF-SLP
Michael J. Murphy, AuD
Debra Wygant MA, CCC-SLP
Kelly Zigarovich, MS CCC-SLP
Lynne Hebert-Remson, PhD, CCC-SLP, BCS-F
Chelsey Browell, Student
Sarah Leskowsky, Student
Patricia Bohlman M.S. CCC- SLP
Olivia Flick, Student
Sarah McMahon, M.S., CF-SLP
Mandy J Maguire, PhD, Associate Professor of Communication Sciences and Disorders, University of Texas at Dallas
Erin Dyer, M.A., CCC-SLP
Charlotte J Molrine PhD, CCC-SLP
Carrie Van Soest
Melissa Kokaly, MS CC-SLP
Maura Dugan, M.A., CCC-SLP
The ramifications for this action are significant. As expected, many speech-language pathologists from the U.S. and abroad do not support this action for several reasons. First, this action gravely limits the scope of treatment for stuttering. Many interventions for preschool stuttering have shown to be effective (Millard, Nicholas, & Cook, 2008; Yaruss, Coleman, & Hammer, 2006; Franken, Kielstra-Van der Schalk, & Boelens, 2005). To select any one approach and mandate its use reflects limited knowledge of the clinical process. What happens when a child receives treatment with the Lidcombe program and doesn’t make progress? Does the child have other treatment options? From this mandate, it would appear that is not the case.
Second, this mandate stifles new and innovative treatment approaches. How are new (and perhaps more effective treatment approaches) expected to emerge when only treatment with an existing evidence-base is mandated? Imagine if all infections were still treated using penicillin because it was an early treatment option. Would the government and medical associations support such a position? Perhaps a clearer question is would the lobbyists of the pharmaceutical industry allow legislators to even remotely consider the idea? Do we think less of ourselves as a profession to allow this to happen?
Third, this mandate highlights a concerning trend of what constitutes “evidence.” While certain treatments might have more data than others, that data does not always mean the treatment is more effective. Evidence-based practice includes current scientific evidence, clinician experience, and client /family values. What if the clinician is not properly trained in the treatment approach? What if the personality of the client, family, or clinician is not a good fit for one particular approach? Surely, the best “evidence” comes not from group data, but the individualized outcome of each client we serve. While group data certainly presents scientific evidence, individual outcomes present actual evidence-based practice. That type of data takes into account all aspects of the evidence-based practice triangle.
Fourth, a mandate such as this one creates obvious ethical questions. Who will train all of the speech-language pathologists to use one approach? Will there be a fee for such training? Is there an arrangement between the association, government, and trainers? These questions are not easily answered with a mandate such as this. Even if there are no financial ties, the appearance of such is obvious.
Finally, while the ramifications for stuttering treatment in Australia are apparent, this mandate has far reaching implications. After the precedent has been established, we would be naïve to think this could not happen with other disorders in all parts of the world. This is not an issue for the stuttering community of Australia to deal with. It is an issue for the speech-language-hearing community of the world to deal with.
So, where do we go from here? Here is a potential plan I would like to suggest:
1. Contact Speech Pathology Australia at policy@speechpathologyaustralia.org.au to express your concerns for this mandate. Stop the trend before it starts.
2. Advocate for reimbursement for stuttering. While the mandate outlined about is beyond concerning, the state of reimbursement for stuttering treatment in the United States can best be described as “dire.” One of our missions should be to work with insurance providers and demand that they pay for stuttering treatment. Somewhere along the way, we have allowed insurance companies to dictate that stuttering treatment should not be reimbursed. We must reverse that trend.
3. Create a consortium of professionals. This would allow a database of treatment outcomes to be collected from clinicians in the field. Not only would this help with reimbursement, but it would also allow publication of data collected from individualized treatment approaches. We are professionals, not technicians. Our clients deserve better than “follow-the-manual” based programs and protocols.
4. Educate. We need to educate our professionals and the public about stuttering. Stuttering is not merely a disruption in the flow of speech. It is much more than that.
As concerning as this mandate is, it can be a positive if we choose to act with reason, courage, and passion.
Craig E. Coleman, M.A., CCC-SLP, BCS-F
Assistant Professor, Marshall University
Coordinator, ASHA SIG-4
References
Franken, M. C. J., Kielstra-Van der Schalk, C. J., & Boelens, H. (2005). Experimental treatment of early stuttering: A preliminary study. Journal of Fluency Disorders, 30(3), 189-199.
Millard, S. K., Nicholas, A., & Cook, F. M. (2008). Is parent-child interaction therapy effective in reducing stuttering? Journal of Speech, Language, and Hearing Research, 51(3), 636-650.
- Yaruss, J.S., Coleman, C., & Hammer, D. (2006). Treating preschool children who stutter: Description and preliminary evaluation of a family-focused treatment approach. Language, Speech, and Hearing Services in Schools, 37, 118-136.
Update: In order to provide both sides of the discussion, I am including the statement from Speech Pathology Australia: http://www.speechpathologyaustralia.org.au/all-latest-news/1997-budget-submission-2015-clarification
While this statement seeks to clarify that this is not an endorsement of one approach, advocating for reimbursement for only one approach certainly seems to send the opposite message. Many insurance companies will not pay for stuttering treatment here in the U.S. But responding to that by supporting a policy that would cover only one approach would be very dangerous and erroneous.
It is also important to understand that once Medicare programs establish a policy, private payers soon follow suit. It's very naive to believe this policy won't have major negative ramifications in the long run.While it may benefit some children in the short term, there is no doubt in my mind it will not benefit people who stutter or our profession in the long term.
Signatures of Support for this Post:
J Scott Yaruss, PhD, CCC-SLP, BCS-F, F-ASHA Associate Professor and Director of MA/MS Programs in Speech-Language Pathology, University of Pittsburgh Coordinator of Clinical Research, Children's Hospital of Pittsburgh of UPMC
Vivian Sisskin, M.S., CCC-SLP, BCS-F, ASHA-F Clinical Professor, University of Maryland
Charlie Osborne, MA, CCC-SLP, University of Wisconsin-Stevens Point
Joseph Donaher, Ph.D., CCC/SLP
Kathleen Scaler Scott, Ph.D., CCC-SLP, BCS-F
Corrin G. Richels, Ph.D. CCC-SLP
Farzan Irani, Ph.D. CCC-SLP
Dale F. Williams, Ph.D., CCC-SLP, BCS-F
Brooke Leiman MA, CCC-SLP
Mary Weidner, M.S., CCC-SLP
Mary Beth Mason-Baughman, PhD, CCC-SLP
Lester F. Aungst, PhD, CCC-SLP
Joel Korte, MA CFY-SLP
Peter Reitzes, MA CCC-SLP
Keely Bauer, M.S., CCC-SLP
Joseph F. Klein, Ph.D., CCC-SLP
Ashley Krieger MS CCC-SLP
Angela Farster, MA, CCC-SLP
Julia Rademacher, M.M., M.A., CCC-SLP
Sara MacIntyre, MA CCC-SLP
Andy McMillin, MA, CCC-SLP
Valerie Ostergaard, MS CCC-SLP/L
Katie Gore, MA, CCC-SLP
Stephanie Coppen, Parent
Courtney Alcott, Parent
Patricia Mason
Joan M. Ross Parent of a PWS
Kathryn Dorney MA/CCC-SLP
Jocyline Graham, M.A., CCC-SLP
Bethany Tileston, MA, CCC-SLP
Katharine Schwartz, CCC-SLP
Zeina Mvemba, MEd CF-SLP
Julie North M.S. CCC/SLP
Malayna Bailey, Student
Steve Marchant MS, CCC-SLP
Courtney Luckman, Student
Joan Duffield. Parent and teacher
Jianliang Zhang, PhD
Karen Spohn, parent
Janet Mascaro, MA CCC-SLP
Sue Shumway, Parent
Melanie Rogers, Parent of PWS
Jean Sawyer
Julie Bourke Parent
Christine Dits, M.A., CF-SLP
Tahisha Bishop
Kimberly A. McGinley, MA CCC-SLP
Valery E. Yura, M.Ed. CCC-SLP
Kathleen Helfrich-Miller, Ph.D. CCC-SLP
Nannette Crawford MA CCC-SLP
Jayme M. Lundy, MA CCC-SLP
Jennifer Coleman MS CCC-SLP
Leigh Growall MA-CCC-SLP
Karen L. Pallies, M.A., CCC-SLP
Brittany Ireland, M.S. CCC-SLP
Lynn A.C. Golightly M.S. CCC-SLP
Taz Quesinberry, M.A., CCC-SLP
Patty A. Walton, M.A, CCC-BCS-F
Timothy Flynn, M.S., CCC-SLP
Midori Rodriguez, MS, CF-SLP
Ann F. Brandt M.A., CCC-SLP
Meghan Decker, M.S. CCC-SLP
Katie Belardi, M.S., CCC-SLP
Leslie Eckenthal, MS, CCC-SLP
Brittany Fisher, M.S. CF-SLP
Jennifer Moak, M.A., CCC-SLP
Alison Oniboni, M.S., CF-SLP
E. Brooke Thevenin, student
Katrina Stewart, M.S., CF-SLP
Pei-Tzu Tsai, Ph.D., CCC-SLP
Susan Hamilton MA CCC SLP BCS-F
Jami Ellis Kukla, M.S., CCC-SLP
Claudia Kikuta, M.S., CCC-SLP
Anne Elsweiler, MA, CCC-SLP, BCS-F
Lee Caggiano, MA CCC SLP BCS-F
Bailey V. Levis, M.S., CCC-SLP
Joan Lada Butterworth, M.S., CCC-SLP, BCS-F
Jennifer Berkey, M.S., CCC-SLP
Julie Anderson, Ph.D., CCC-SLP
Erin Bass, Student
Michelle A. Jones, M.A., CCC-SLP
Heather L. Grossman, PhD, CCC-SLP, BCS-F
Beth Friedman, MA, CCC-SLP
Carin Keyes, MS CCC-SLP
Nancy Borkman, MS, CCC-SLP
Olivia Hughes, student
Dimitris Marousos
Magda Gammon
Lee Reeves
Amanda Bivens MS, CF-SLP
Kristin Holler, student
Bryan Brown MA CCC-SLP
Sherry Johnson MA, CCC-SLP
Rachel Johnson, Student
Marybeth Allen, MA-CCC-SLP
Mary Wallace, MA-CCC-SLP, BCS-F
Victoria Reynolds, CPSP
Emily Kennedy MA,CCC-SLP
Robert W. Quesal, Ph.D., CCC-SLP
Audrey Holland, Student
Karin Sorg, MS Ed., CCC-SLP
Kay Wallis, MS/CCC, BCS-F
Katie Moore, MS, CCC-SLP
Debbie Musgrave M.S. CCC-SLP
Katie Micco, MS CCC-SLP
Katerina Ntourou, PhD, CCC-SLP
Inbal K. Vellucci, M.A., CCC-SLP
Brenda Vogel, MA, CCC-SLP
Jennifer Barna, MA CCC-SLP
Frances Elvins, M.S. CF-SLP
Michael J. Murphy, AuD
Debra Wygant MA, CCC-SLP
Kelly Zigarovich, MS CCC-SLP
Lynne Hebert-Remson, PhD, CCC-SLP, BCS-F
Chelsey Browell, Student
Sarah Leskowsky, Student
Patricia Bohlman M.S. CCC- SLP
Olivia Flick, Student
Sarah McMahon, M.S., CF-SLP
Mandy J Maguire, PhD, Associate Professor of Communication Sciences and Disorders, University of Texas at Dallas
Erin Dyer, M.A., CCC-SLP
Charlotte J Molrine PhD, CCC-SLP
Carrie Van Soest
Melissa Kokaly, MS CC-SLP
Maura Dugan, M.A., CCC-SLP
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