Second Opinion
about the necessity of treating every child who
Treatment Decisions for
Young Children Who
Stutter: Further Concerns
and Complexities
Roger J. Ingham
University of California, Santa Barbara
Anne K. Cordes
The University of Georgia, Athens
D
rs. Curlee and Yairi’s (1997) recent
paper provided some interesting and
provocative comments regarding
treatment for children who have been stuttering
for less than approximately 2 years. Their paper
raised several issues that were important,
complex, and fully deserving of critical assess-
ment. It was accompanied by two “Second
Opinion” commentaries (Bernstein Ratner, 1997;
Zebrowski, 1997), each of which addressed some
Ingham additional pieces of this complex area, and each
of which essentially agreed with Curlee and Yairi
on two general points: that some children who
stutter may not need clinical services, and that we
have reason to be dissatisfied with the available
evidence about treatment effectiveness for
children who stutter. We do not entirely disagree,
but the purpose of this response is to present an
opinion about Curlee and Yairi’s paper that
challenges their premises and their conclusions in
several areas. These areas include the incidence
and prevalence of stuttering, and whether those
data provide evidence of high recovery rates;
several issues related to determining whether
Cordes treatments are effective and whether they should
be recommended; and several issues related to
the experimental evaluation of treatment
effectiveness.
Incidence, Prevalence, and
Mathematically Necessary
Recovery
Curlee and Yairi (1997) began with the
premise that there is “considerable disagreement
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stutters as soon after onset as possible and
about the risks involved if their treatment is
postponed for a while” (p. 8). Some of this
disagreement, according to Curlee and Yairi,
stems from the differences in the prevalence
and the lifetime incidence of stuttering and
from our knowledge about the spontaneous
remission of stuttering. They wrote that the
“lifetime incidence of stuttering in the United
States and western Europe is generally believed
to approximate 4 to 5%…whereas its preva-
lence [ranges] from 0.5 to 1%” (1997, p. 8). If
these numbers are correct, wrote Curlee and
Yairi, then it is “mathematically transparent
that…75% to 90% of all who begin” (p. 9) to
stutter will not continue to do so. In addition,
between 32% and “over 80%” (p. 9) of these
recoveries are said to be “spontaneous or un-
aided” (p. 9).
Curlee and Yairi are not the first to summa-
rize the prevalence and incidence literature as
showing a 75–90% recovery rate, but the litera-
ture is not entirely consistent with such an
interpretation. Table 1 summarizes the studies
listed by Bloodstein (1995, his Tables 3 and 6)
that have been conducted since 1950.1 Esti-
mates of the lifetime incidence of stuttering
range from 0.70% to 15.40% across these stud-
ies, whereas estimates of prevalence range from
0.30% to 2.12%. These differences clearly
reflect substantial and significant variability
across studies, and they also argue against
Curlee and Yairi’s (1997, p. 9) claim that it is
“mathematically transparent” that “75% to 90%
of all who begin” to stutter will recover: At the
extreme, these numbers actually suggest that
the lifetime incidence of stuttering is only 0.7%
(Culton, 1986) at the same time that its preva-
lence is somehow as high as 2.12% in junior-
high and high-school students (Gillespie &
Cooper, 1973). It is certainly not mathematically
simple to translate such data into a 75–90% re-
covery rate.
Recommending Treatments
for Stuttering
The next section of Curlee and Yairi’s paper
argued that it may be appropriate to withhold
treatment for young children not only because
of the supposedly high rate of natural recovery
but also because “the efficacy of early interven-
tions with children soon after stuttering onset is
1
An additional nine studies in Bloodstein’s Table 3, and
three studies in his Table 6, were conducted between 1893
and 1942. Inclusion of these studies would only lengthen
our Table 1 without changing the conclusions drawn, as
readers may verify.
August 1998
© American Speech-Language-Hearing Association
 TABLE 1. Summary of incidence and prevalence studies of stuttering reported since 1950, selected
from those summarized by Bloodstein (1995, Tables 3 and 6).

Study N Population %

Prevalence studies
Schindler (1955) 22,976 Grades 1–12 0.55
Hull (1969) 6,287 Grades 1–12 0.30
Gillespie & Cooper (1973) 5,054 Grades 7–12 2.12
Leavitt (1974) 10,445 Grades 1–6 0.84
Leavitt (1974) 10,449 Grades 1–6 1.50
Brady & Hall (1976) 187,420 Grades K–12 0.35
Hull et al. (1976) 38,802 Grades 1–12 0.80
Leske (1981) 7,119 Grades 1–6 2.00

Incidence studies
Glasner & Rosenthal (1957) 996 First grade 15.4
Andrews & Harris (1964) 1,000 Birth–16 4.9
Andrews & Harris (1964) 206 Adults 4.8
Sheehan & Martyn (1970) 5,138 Freshmen/graduates 2.9
Dickson (1971) 3,923 K–12 9.4
Cooper (1972) 5,054 High school 3.7
Porfert & Rosenfield (1978) 2,107 University students 5.5
Seider, Gladstien, & Kidd (1983) 1,857 Stutterers’ relatives 13.9
Culton (1986) 30,586 University freshmen 0.7

essentially unknown” (p. 10). In expanding on
this idea, Curlee and Yairi drew on a confer-
ence presentation by one of us (Ingham, 1996)
that has since become a book chapter by both
of us (Ingham & Cordes, in press). In this chap-
ter, we criticized current stuttering treatment
research, asserting that our discipline and our
clients are poorly served when researchers
promote treatments that are supported by inad-
equate treatment outcome data. We provided
specific examples of articles that recommended
treatment procedures that were undocumented,
at best, and shown to be ineffective, at worst.
We also pointed out that there is, in fact, an
established and growing body of treatment
research studies that do satisfy a relatively
standard evaluation framework, providing
repeated speech measures from before, during,
and after treatment and from both within- and
beyond-clinic conditions (e.g., Craig et al.,
1996; Kully & Boberg, 1991; Lincoln, Onslow,
Lewis, & Wilson, 1996; Martin, Kuhl, &
Haroldson, 1972). These studies consistently
report clinically significant benefits relative to
untreated control conditions, some for very
young children, and these benefits may also be
evaluated through comparisons with other
reports of children who have not received pro-
fessional treatment. Finally, we presented a re-
analysis of available data that we believed
strongly suggested two conclusions: that treat-
ment should be offered to young children who
stutter, and that delaying treatment, even for as
little as 15 months after onset, may diminish
the chances that children will recover.2
Curlee and Yairi (1997), on the other hand,
concluded that treatment may not need to be
offered to young children and that delaying
treatment will have no deleterious effects:
“Our contention is that active monitoring of
young preschoolers during the first 2 years of
stuttering…rather than intervening actively,
permits the unaided remission of stuttering for
most of them and does not adversely affect later
treatment of stuttering for those who do not
stop” (Curlee & Yairi, 1997, p. 12). Clearly,
Ingham and Cordes (in press) and Curlee and
Yairi (1997) have drawn diametrically opposed
conclusions from the same research and clinical
literature, making opposite recommendations
for young children who stutter. There would
appear to be several factors underlying this dis-
agreement, several of which we explore below.
Distinguishing Between
Disfluency and Stuttering
One of the first issues that deserves further
consideration is as simple as the basic fact that
2
The more important implication of these findings, actually,
is that parents should be given information about the
benefits that may occur if they do try to intervene in their
child’s stuttering. Studies reported by Onslow and
colleagues, and others, strongly suggest that children’s
stuttering can be reduced if parents employ relatively mild
verbal contingencies for occasions of stuttering and for
periods of fluent speech production. There is, on the
contrary, absolutely no evidence that such procedures will
cause stuttering to increase or become chronic.

Ingham • Cordes 11
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 a disfluency is not necessarily a stuttering.
Measuring disfluencies cannot be equated with
measuring stuttering, because measuring all
disfluencies would include measuring both
normal and stuttered disfluencies. Systems that
distinguish between stuttered disfluencies and
nonstuttered disfluencies (e.g., Conture, 1990;
Ryan, 1974; Wingate, 1964) also fail, because
it is consistently possible to find examples of
speech behaviors that cannot be appropriately
classified under such systems (the attempt to
define all between-word disfluencies as normal
provides one clear example; Cordes & Ingham,
1995). This problem has led some researchers
to measure “stutter-type” (Meyers, 1986) or
“stutter-like” (Yairi & Ambrose, 1992) dis-
fluencies, an equivocating approach that does
not solve the problem of determining whether
the reported data are meant to represent stutter-
ing or not. Much other current research about
stuttering is conducted simply in terms of dis-
fluencies, with no attempt to provide data about
stutterings at all.
The implications of such basic definitional
problems are enormous, especially for very
young children. They lead to diagnostic criteria
that label children as stuttering if their speech
includes “10% or more total disfluency” (Gre-
gory & Hill, 1993, p. 28), whether or not that
speech includes any atypical, abnormal, or
stuttered disfluencies. They also lead to important
difficulties in evaluating the effects of treatment:
A report that disfluencies were reduced is not
necessarily a report that stuttering was reduced
and should not be interpreted as such.
Given these complexities, any meaningful
discussion about whether children are stutter-
ing, or about whether children need treatment
for stuttering, should begin by affirming that
normal disfluency will not be confused with
stuttering and by documenting that the children
in question were, in fact, stuttering. Curlee and
Yairi (1997) did not address this seemingly
basic issue of defining their terms, a problem
that may have led them to some questionable
conclusions. They wrote, for example, that “a
variety of different treatment procedures may
be capable of eliminating or significantly reduc-
ing almost all young children’s stuttering” (p.
10), basing this statement on the evidence that “a
number of different intervention procedures…are
reported to have high rates (e.g., >85%) of
success or ‘recovery’ (Fosnot, 1993; Martin,
Kuhl, & Haroldson, 1972;…Starkweather,
Gottwald, & Halfond, 1990)” (pp. 9–10). The
definitional problem here is that some of these
papers did not report data in terms of children’s
stuttering: Fosnot (1993) discussed disfluencies
and stutter-type disfluencies, so her data may or
may not be related to changes in stuttering, and
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Starkweather et al. (1990) discussed very little
data at all (as Curlee and Yairi pointed out).
Distinguishing Among General
Approaches to Treatment
The determination of what constitutes treat-
ment is equally critical to a meaningful discus-
sion about whether to provide treatment for
children who stutter. Three related issues are
important here: whether treatment must be
administered by a professional, whether treat-
ment includes direct or indirect procedures, and
whether a procedure should be referred to as a
treatment if there is little or no evidence that it
will be effective.
The question of whether treatment must be
administered by a professional was raised by
Curlee and Yairi in the context of spontaneous
recovery, and it is related to previous sugges-
tions that parent- or self-initiated procedures
might be a relevant factor in recoveries that
appear to occur without professional interven-
tion (Finn, 1996; Ingham, 1983). Curlee and
Yairi argued that “most advocates of this view
do not address the apparent failure of care-
givers’ interventions” (p. 11) when stuttering
persists. In fact, Ingham (1983) addressed this
very issue: “there is also no evidence that these
procedures are necessarily effective in reducing
stuttering in all children. All that we have to
look to is some evidence that they may be ef-
fective with some children who stutter” (p.
123). The importance of this point is high-
lighted by the fact that Curlee and Yairi used it
to support another suggestion that early inter-
vention for stuttering may be unnecessary:
“If…intervention or treatment is restricted to
activities that are undertaken by or under the
supervision of certified clinicians trying to
remediate stuttering, current evidence indicates
that 60% to 70% of preschool age children who
begin to stutter stop within the first 2 years of
onset without having received any kind of such
professionally directed intervention” (p. 11).
The premises underlying this statement de-
serve some thoughtful scrutiny. First, we see no
reason to reserve the label “treatment” for cases
where a professional was involved. Adults often
provide treatments for themselves or for their
children, for everything from headaches to
behavioral, emotional, or learning problems.
Second, we know of no data to suggest that
“60% to 70%” of all children who begin to
stutter receive no professional intervention at
all. Third, there is evidence that some children
who recover without professional intervention
are exposed to procedures that are known to
reduce stuttering (Finn, 1996; Ingham, 1976,
1983; Martin & Lindamood, 1986). In addition,
August 1998
 Ingham (1983) and Martin and Lindamood
(1986) showed that direct parent intervention
was generally reported more frequently among
recovered than among nonrecovered stutterers.
The conclusion that a group of children stopped
stuttering without professional intervention, in
other words, should not be equated with the
conclusion that they all stopped stuttering in the
absence of actively administered procedures
that are known to reduce stuttering in some
children—that is, depending on how the word
is defined, without treatment.
This discussion is also related to the differ-
ence between direct and indirect treatments for
children’s stuttering. Direct treatments, in this
context, are usually defined as those that target
the child’s speech behaviors (whether through
the parent or through a clinician); indirect treat-
ments are usually defined as those that target
only environmental or parental behaviors.
Curlee and Yairi did not distinguish between
the two, but Zebrowski (1997) made several
recommendations specifically for indirect treat-
ment. Bernstein Ratner (1997) also noted that
indirect treatments are “undoubtedly preferred
to direct treatment by clinicians” (p. 30) for
early stuttering. She suggested several possible
reasons for this preference, including the com-
ment that “it is unclear to me whether most of
the major tasks of direct stuttering treatment
can be performed by the average child as young
as 2;6 years…for the simple reason that they
are not metalinguistically capable of many of
the behavioral features of these programs” (p.
30). There are at least two large classes of di-
rect treatments, however, that are ideally suited
to very young children, that require no meta-
linguistic awareness, and that have been shown
to be effective at reducing young children’s
stuttering. These include punishment of unde-
sired responses combined with reinforcement
of desired responses, which was discussed
above (Martin et al., 1972; Onslow, Andrews,
& Lincoln, 1994), and procedures that depend
on controlling the length or complexity of the
child’s utterances (by controlling the speaking
situation; no metalinguistic awareness is re-
quired) (Costello, 1983; Ryan, 1974).
The distinctions between professionally
directed and parent-directed treatment, and
between direct and indirect treatment strategies,
are both related to the question of whether a
treatment should be referred to as a treatment if
it has not been demonstrated to be effective.
Bernstein Ratner (1997), for example, recom-
mended some indirect home management strat-
egies, because “some controlled experimental
data (Stephenson-Opsal & Bernstein Ratner,
1988) as well as observational data (Winslow
& Guitar, 1994), validate the palliative effects
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of some types of modifications to the home com-
munication environment” (p. 30). The problem
with this suggestion is that these studies simply
do not provide experimentally compelling evi-
dence that the procedures mentioned can improve
children’s stuttering. The Stephenson-Opsal
and Bernstein Ratner study, for example, em-
ployed an AB treatment design, with no experi-
mental control. The subjects were 2 boys who
stuttered: one aged 3;3 who may have con-
founded the results by being concurrently
enrolled in another “behavior management
program” (1988, p. 50) and one aged 6;2. They
were recorded for unspecified amounts of time
in mother-child dyads, and the “palliative ef-
fects” were a mean 28% and 45% decrease
(respectively) in the children’s “mean percent
time disfluent.” No evidence was presented to
show that this decrease was stable, that it ex-
ceeded base-rate variability, that it reflected
beyond-clinic performance, or that it reflected
changes in the children’s stuttering (as op-
posed to normal disfluency; see above). In
short, this study provided no evidence that the
“intervention techniques…can show relatively
immediate reductions in stutter frequency that
are time-linked to the intervention manipula-
tion” (Bernstein Ratner, 1997, p. 32).
Winslow and Guitar (1994) obtained similar
results. One boy who stuttered, aged 5;9, com-
pleted an ABAB experimental design, where
the A condition was routine interaction and the
B condition was “structured turn taking” during
conversations at meal time in the child’s home.
Results showed, at best, a 50% reduction in
“stuttering-type disfluencies” during the struc-
tured turn-taking condition in the home (from a
mean of 7–20 stuttering-type disfluencies per
300 words to a mean of 5–10 stuttering-type
disfluencies per 300 words), with no data from
other settings, no follow-up data, and no evi-
dence that the child’s stuttering (not stuttering-
type disfluencies) was decreasing. This change
might be “palliative,” but it cannot be justified
as an experimentally verified and effective
treatment for children’s stuttering, as we would
define those terms.
Zebrowski’s (1997) response to Curlee and
Yairi was similar to Bernstein Ratner’s in this
respect and raises similar issues. Zebrowski
provided a series of decision “streams,” including
suggesting that clinicians could introduce indirect
treatments for certain children. Suggested proce-
dures included “modeling a reduced speaking
rate and increased turn-switching pause duration,
allowing the child to finish his conversational
turn without interruption, and so forth” (1997, p.
25), methods that Zebrowski justified by refer-
ence to publications by Kelly (1993, 1995) and
Zebrowski, Weiss, Savelkoul, and Hammer
Ingham • Cordes 13
 (1996). Kelly offered less critical reviews of
this literature than Nippold and Rudzinski
(1995), who could find little supporting evi-
dence for these procedures. Zebrowski et al.
(1996) did offer some data on the effects of
slowing the mother’s speech rate, from a study
of 5 children who stuttered (aged 2;10–7;5)
and their mothers, but those data showed only
variable and nonsignificant effects on the
children’s disfluencies in a clinic setting. In
other words, as Nippold and Rudzinski (1995)
concluded previously, not one of the indirect
treatment strategies recommended by either
Bernstein Ratner (1997) or Zebrowski (1997)
can be justified on the grounds of data that
should be interpreted as showing clinically
significant reductions in children’s stuttering.
The Desirable Outcomes for
Children Who Stutter
Arguments about whether treatment is desir-
able or necessary for young children who stutter
are further complicated by arguments about the
desired treatment outcome. Whether adminis-
tered by a professional or not, whether direct or
indirect, whether administered immediately or
delayed, we assume that the goals of treatment
for a child who stutters are twofold: to eliminate
the stuttering and to allow the child to grow up
without any of the social or emotional conse-
quences of living with a communication disor-
der. We also believe that accomplishing the
former is among the most straightforward ways
to achieve the latter (Lincoln & Onslow, 1997).
One of the many complications in this area
involves determining whether stuttering has
been eliminated. Clearly, this determination
cannot be made from brief speech samples
recorded within a single treatment environ-
ment; there are sufficient reports of stuttering
varying across time and place, and of “clinic-
bound fluency,” that this point should be self-
evident (Andrews & Ingham, 1972; J. Ingham,
1989; Ingham & Packman, 1977; Lincoln &
Onslow, 1997; Lincoln et al., 1996; Martin et
al., 1972; Onslow, Costa, & Rue, 1990; Onslow
et al., 1994; Reed & Godden, 1977; Ryan,
1971, 1974; Ryan & Van Kirk Ryan, 1983).
Equally, this determination cannot be made if
data are reported only in terms of disfluencies,
rather than in terms that make it clear whether
the child is stuttering or not, as discussed above.
The longitudinal study of Yairi and col-
leagues, referred to by Curlee and Yairi (1997),
exemplifies some of the difficulties in this area
and is directly relevant to Curlee and Yairi’s
recommendations about delaying treatment.
First, the performance criteria for defining
children as “recovered” in the longitudinal
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study have varied from publication to publica-
tion (Onslow & Packman, in press). Yairi and
Ambrose (1992) required, among other criteria,
that a child display not more than 2.99 SLDs
per 100 words to be classified as “recovered.”
Later studies, however, have allowed as many
as 4 SLDs (see Paden & Yairi, 1996, p. 983;
Watkins & Yairi, 1997, pp. 387–388; Ambrose,
Cox, & Yairi, 1997, p. 569). At the same time,
the opposite problem is also present: In Yairi
and Ambrose’s (1992, 1996) data, 4 of the 8
continuing stutterers displayed less than 2.99
SLDs at Visit 5 in the clinic but were still re-
garded as nonrecovered (presumably because
of parental reports that these children still stut-
tered outside the clinic). These and other com-
plexities in the data from Yairi and colleagues
would be unremarkable were it not for the fact
that these are the numbers used by Curlee and
Yairi (1997, p. 10) to claim that the rate of recov-
ery in untreated stutterers within the longitudinal
study is as high as 89%. In a more general sense,
these conflicting reports simply demonstrate the
importance of establishing and following clear
criteria for determining when a child will be said
to have recovered from stuttering, as well as the
difficulties inherent in doing so.3
The Effects of Delaying Treatment
As Curlee and Yairi and others have ob-
served, there is unquestionably some number of
children who stutter for several months and
then stop stuttering without formal treatment.
For example, of the 43 children who ever stut-
tered in Andrew and Harris’s 1964 longitudinal
study, approximately 18 children stopped stut-
tering within 6 months.4 They labeled most of
these children “Transient Nonfluent,” but such
3
The issue is complicated by the fact that Yairi and
Ambrose (1996) published a correction to the Yairi and
Ambrose (1992) data that, itself, may require correction. In
a personal communication to one of us (R. I.) regarding the
original correction, Ambrose (personal communication,
April 22, 1996) reported that by Visit 5 there were 13
Recovered and 8 Continuing stutterers. The mean SLD
scores for both groups of subjects, as shown in the 1996
Erratum, correspond precisely to that number of subjects
within each category. Yairi and Ambrose (1996) also
reported, however, that at Visit 5 there were 14 Recovered
and 7 Continuing stutterers.
4
Readers should be aware that the Andrews and Harris study
was not without its problems (Ingham, 1976). The data from
this study were first displayed in a figure (Andrews & Harris,
1964, p. 31) that has been reproduced in various editions of
Bloodstein’s A Handbook on Stuttering. In 1984, however,
Andrews (1984, p. 4) made unexplained changes to the years
of stuttering onset and recovery for 10 of the 43 children. A
comparison between the original table (Bloodstein, 1981, p.
84) and the revised table (Bloodstein, 1987, p. 94) shows
several changes in the longitudinal data for which no
explanation has ever been provided.
August 1998
 children may display both speech behaviors and
emotional and social reactions that are indistin-
guishable from those exhibited by older chil-
dren or adults who stutter. Given that these data
do suggest that some children may stutter for
something less than 6 months and then stop, we
would agree with the principle of waiting to
initiate treatment to this extent: It certainly does
make sense for clinicians to consider waiting
perhaps 3 to 6 months from the time of stutter-
ing onset before initiating intervention, if wait-
ing does not introduce social or emotional
pressures for the child or for the parents and if
there is some indication that the individual
child in question is improving without treat-
ment. One issue that Curlee and Yairi did not
mention, however, is that 3 to 6 months or
more has often passed before parents bring a
child to a speech-language pathologist in the
first place, making the question of a 6-month
waiting period essentially moot in many cases.
We emphasize here that the most effective
use of a waiting period would not be simply to
wait in the hope or expectation that the child
will recover spontaneously. Instead, the parents
and the clinician could collect recorded base-rate
speech samples, at least monthly and in mul-
tiple speaking situations, to provide a rational
and data-based source for deciding whether
stuttering is increasing or decreasing for a par-
ticular child. Again, Curlee and Yairi (1997)
reported data from Yairi and colleagues’ longi-
tudinal study that are relevant to this point and
that we would interpret as potentially confirm-
ing the need for treatment within 12 months
after onset. Repeated measurements of children
in the longitudinal study showed that percent-
ages of SLDs declined over the first 12 months
in those children who stopped stuttering within
12 months, whereas the percentage of SLDs
“either increased or remained at relatively
stable levels throughout this period among
those whose stuttering persisted” (Curlee &
Yairi, 1997, p. 12). We would argue that these
data provided ample justification for introduc-
ing treatment for the children whose stuttering
was persisting, especially if the failure to pro-
vide treatment was related to these children’s
“increased risk of stuttering for another 2 years
or longer” (Curlee & Yairi, 1997, p. 12). Curlee
and Yairi noted that older children “most likely
constitute a subgroup of stuttering children who
have passed through the primary remission
period of the stuttering population” (1997, p.
10). They continued, however, with the state-
ment that these older children “are, therefore,
much more likely to possess characteristics or
predispositions that result in chronic stuttering”
(1997, p. 10). We would argue that providing
treatment for younger children is preferable to
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withholding treatment from children who are
clearly not recovering and then concluding,
when they are older, that untreated and unre-
covered children must have had a predisposi-
tion to display chronic stuttering.
Both Zebrowski (1997) and Bernstein
Ratner (1997) also made recommendations that
are relevant to decisions about when to intro-
duce treatment. Zebrowski presented five po-
tential treatment plans, each based on a combi-
nation of suggested risk factors. It is only the
last of these, Plan E, that includes any mention
of direct treatment, designed to decrease the
child’s stuttering, and the child must be “24–36
months postonset” (p. 26) to qualify. Children
in Plan C are allowed to stutter for up to 24
months without direct treatment; parents here
“can be informed about changes in their speech
that might have an indirect fluency-inducing
effect on the child” (p. 26). Children in Plan D
have also been stuttering for up to 24 months,
and their parents are “often…beginning to
suspect that the child may not ‘grow out of it’”
(p. 26). We simply see no justification for sug-
gesting that a child who is clearly not “growing
out of it” should be required to wait for 2 full
years before being given access to treatments
that are known to be more effective if used
within 15 months of stuttering onset.
Again, as we interpret the literature, there is
compelling evidence that the probability of
successful treatment is lower for older children,
and the decision to delay stuttering treatment
should be made with full awareness of this
evidence. The comparisons that we presented in
the Ingham and Cordes (in press) paper showed
that 81.8% of preschoolers who received treat-
ment met our criteria for satisfactory outcome,
but only 54.2% of school-age children who
received treatment met these criteria, for treat-
ment studies that provided data from treatment
evaluation procedures. Similar comparisons
showed that 85.7% of children who received
treatment within 15 months of stuttering onset
met our recovery criteria (7/9 boys and 5/5
girls), whereas only 59.4% of children who
received treatment starting more than 15 months
after stuttering onset did so (16/28 boys and 3/4
girls). Other evidence about the importance of
early treatment can be found in the reports of
Onslow and colleagues, for example, who have
reported comparatively better results at long-
term follow-up for children aged 2–4 years
(Onslow et al., 1994) than for children aged
7–12 years (Lincoln et al., 1996) who received
essentially the same treatment.
Curlee and Yairi argued, in commenting on
these comparisons, that there are a “number of
risks involved in combining data from different
studies…[including] such factors as subjects’
Ingham • Cordes 15
 ages, time since onset, sex, and family history”
(p. 10).5 We agree, but the comparisons pre-
sented by Ingham and Cordes (in press) were,
in fact, completed separately for boys and girls
of different ages (preschoolers and school-age)
and of different times since onset [more or less
than 15 months, a dividing line chosen based
on Yairi and Ambrose’s suggestion that
“chances for chronicity increase approximately
15 months after onset” (1996, p. 73)]. The
claim that a particular treatment was solely and
directly responsible for the recovery of the
children who received it is different from the
claim that the children who received a treat-
ment recovered, and this is an important dis-
tinction. Nevertheless, and even given the many
terminological difficulties that we have raised
here, our comparisons consistently showed that
children who received their treatment relatively
early displayed more substantial treatment
benefits than children who received their treat-
ment relatively late, even when “late” treatment
was defined as only 15 months postonset. Noth-
ing in Curlee and Yairi’s comments on this
issue alters this conclusion.
Treatment Research
Methodology
Curlee and Yairi’s final section on “Re-
search Needs and Ethical Issues” begins by
acknowledging that treatment for very young
children who stutter can be effective, and that
some interventions can be “causally related to
the changes reported in some children’s stutter-
ing” (p. 14). Nevertheless, they still hesitate to
recommend treatment for young children, be-
cause of the “absence of scientifically credible
treatment outcome data” (p. 15). We do agree,
as discussed above, that there is an absence of
credible data to support many of the procedures
that are recommended as treatments for chil-
dren who stutter, but these issues also deserve
to be more carefully addressed.
Curlee and Yairi suggested that the use of
“randomly assigned, untreated control groups has
long been viewed as essential for evaluating
treatment effectiveness” (p. 15) and that it is
“critically important…that such important scien-
tific standards not be abandoned until there is
sufficient evidence available” (p. 15). Untreated
control groups are by no means universally ac-
cepted, however, for two distinct but overlapping
5
They also rightly observed that one of the studies included
in our comparisons (Ramig’s 1993 historical study of
untreated children) was a study of older children, not of
very young preschoolers. But Ramig’s study also included
8 children, including 2 girls, who were assessed within 15
months of reported onset—and of those 8, only 1 boy
recovered.
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reasons (both of which Curlee and Yairi also
recognized): an untreated control group may be
scientifically unnecessary, and an untreated con-
trol group may be unethical (Lewin, 1995). These
issues are complex, in part because the overriding
principle of treatment research should be to pro-
vide the best possible treatment to all participants
(World Medical Assembly, 1989). If it truly is
not known whether the treatment in question will
be any better than no treatment at all, then a no-
treatment control group can provide a scientifi-
cally relevant and entirely ethical comparison.
This is not the only option, however; investiga-
tors can compare different components or levels
of a treatment, or compare newer and older treat-
ments, both procedures that have been used ef-
fectively in evaluating treatments for stuttering in
adults (e.g., Ingham, Andrews, & Winkler, 1972;
Perkins, Rudas, Johnson, Michael, & Curlee,
1974).
Large-scale treatment trials may also be
appropriately abandoned when treatment ef-
fects become so obvious that it is no longer
defensible to deny those benefits to the control
group. Such decisions are often made using the
same logic that Sidman (1960) employed to
determine the number of subjects that are
needed before researchers will accept that a
powerful treatment has been identified. If a
treatment is introduced, for example, to a rela-
tively small number of similarly afflicted pa-
tients, all of whom had shown stable (or dete-
riorating) base-rate levels, if all immediately
reduce their disorder when treatment is intro-
duced, and if this effect is replicated across
clinics or laboratories, then it is not necessary
to repeat the procedure with too many other
patients before clinical scientists should accept
that the treatment will most probably have the
same positive effects on the next patient. The
possibility certainly does exist that the next
subject might respond differently, but similar
problems of external validity are evident in the
assumption that averaged findings from a large
group are applicable to any one particular sub-
ject. More importantly, sequential analysis
(Wald, 1947) can establish the probability that
a sequence of consistently positive (or nega-
tive) treatment responses could not have oc-
curred by chance (Bross, 1952), without the
need for the sampling-theory assumptions of
large-group research.
Curlee and Yairi did suggest that the studies
needed to provide credible treatment outcome
data could begin with “single-subject experi-
mental designs…to assess the effects of differ-
ent treatment procedures in an unequivocal
manner” (p. 16). At least eight studies over the
past two decades have done precisely that, and
these were cited by Curlee and Yairi. They then
August 1998
 proceeded to suggest, however, not only that
this information is not sufficient without the
support of group studies, but also that satisfac-
tory treatment designs would require control-
group subjects to receive no treatment for 2
years. It is critically important to recognize, in
addition to recognizing that a no-treatment
control group might not be necessary at all, that
the standard pretest-posttest control-group
design does not require the control group to
remain in no-treatment conditions for the entire
duration of any possible untreated recovery
period. In fact, the design is meant precisely to
allow for untreated recovery, and improvement
in the no-treatment group does not, by any
means, prevent a meaningful comparison from
being made: The question is whether, during
the time period covered by the study, the treat-
ment group shows more improvement than the
no-treatment group (Schiavetti & Metz, 1997).
There is absolutely no reason to accept that
experimentally sound stuttering treatment re-
search would require large groups of children to
remain as untreated controls for 24 full months
postonset, as Curlee and Yairi (1997, p. 16)
would have us believe.
Conclusions
Curlee and Yairi’s (1997) article was pub-
lished in the “Second Opinion” section of this
journal. Zebrowski (1997) and Bernstein Ratner
(1997) presented second and third opinions,
both of which concurred with some of Curlee
and Yairi’s major premises. The purpose of our
response has been to present another opinion
that has diverged sharply in several places from
those presented in the original three papers. We
also suggested that many of the issues raised by
Curlee and Yairi are more complex and more
important than the original papers appeared to
recognize. Most importantly, where Curlee and
Yairi argued that our discipline’s data base and
our discipline’s professional and research ethics
support the idea of waiting to provide treatment
to some children who stutter, we have argued
essentially the opposite.
If our discipline chooses to advocate with-
holding treatment from children who may not
recover without it or chooses to advocate the
use of indirect treatments or treatments that
cannot be shown to be clinically effective, then
we should not be surprised to find ourselves in
the position of needing to “affirm our role as
the ‘experts’ in the identification and manage-
ment of stuttering” (Zebrowski, 1997, p. 21).
We suggest only that the “experts” on the man-
agement of any disorder might reasonably be
expected to base their treatment decisions on
critical analyses of all available data and might
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reasonably be expected to insist on treatments
that have been demonstrated to be effective in
well-designed experimental analyses. One of
the greatest strengths of Curlee and Yairi’s paper,
in this light, may be that they have delivered a
much-needed “reality check” about the status of
stuttering treatment research, and we thank them
for their thought-provoking contributions.
Author Note
Authorship is equal. Preparation of this paper was
supported in part by research grant number 5 R01
DC 00060 from the National Institute of Deafness
and Other Communication Disorders, National
Institutes of Health, awarded to the first author.
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Received October 20, 1997
Accepted March 19, 1998
Contact author: Roger J. Ingham, Department of
Speech and Hearing Sciences, University of Cali-
fornia, Santa Barbara, Santa Barbara, CA 93106
Email: rjingham@ucsbuxa.ucsb.edu
Key Words: stuttering, stuttering treatment,
early intervention
Ingham • Cordes 19