Academic and clinical education in fluency disorders: an update

Journal of Fluency Disorders 27 (2002) 43–63

Academic and clinical education in fluency disorders: an update J. Scott Yaruss a,∗ , Robert W. Quesal b a

Department of Communication Science and Disorders, University of Pittsburgh, 4033 Forbes Tower, Pittsburgh, PA 15260, USA b Western Illinois University, Macomb, IL, USA

Received 7 July 2001; received in revised form 28 November 2001; accepted 4 December 2001

Abstract This paper presents a survey of the academic and clinical education in fluency disorders provided by American Speech–Language–Hearing Association (ASHA)-accredited training programs. Respondents were 159 programs (out of 256, return rate = 67.4%) that completed a questionnaire seeking information about the courses and clinical experiences they require, the expertise of their faculty and supervisors, changes following the 1993 modification of training requirements for the ASHA certificate of clinical competence (CCC), and preliminary plans for changes in preparation for the 2005 standards. Results, which supplement findings from an earlier survey distributed in 1997 (Yaruss, 1999), indicated that nearly one-quarter of programs allow students to graduate without coursework in fluency disorders, and nearly two-thirds allow students to graduate without clinical practicum experiences. Findings suggest a trend toward fewer required classes taught by less experienced faculty, fewer clinical hours guided by less experienced supervisors, and a greater likelihood that students will graduate without any academic or clinical education in fluency disorders. Given the repeated finding that many speech–language pathologists are uncomfortable working with people who stutter, as well as ASHA’s apparent de-emphasis of fluency disorders within the increasing scope of practice in the field of speech–language pathology, these results are a cause for concern about the future of fluency disorders. Educational objectives: The reader will learn about (1) the coursework and clinical practicum experiences that are currently required for students in ASHA-accredited training ∗ Corresponding

author. Tel.: +1-412-383-6538; fax: +1-412-383-6555. E-mail address: [email protected] (J.S. Yaruss).

0094-730X/02/$ – see front matter © 2002 Elsevier Science Inc. All rights reserved. PII: S 0 0 9 4 - 7 3 0 X ( 0 1 ) 0 0 1 1 2 - 7

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programs; (2) trends indicating a reduction in training requirements for fluency disorders; and (3) ways of improving these requirements. © 2002 Elsevier Science Inc. All rights reserved. Keywords: Stuttering; Training; ASHA; Speech therapy

1. Introduction In recent years, many clinicians and researchers in the field have been engaged in an ongoing discussion about the academic and clinical education in fluency disorders that is provided to graduate students in training programs in the United States that are accredited by the American Speech–Language–Hearing Association (ASHA). Evidence of the interest in academic and clinical training can be seen in numerous publications (e.g., Brisk, Healey, & Hux, 1997; Leith, 1971; Mallard, Gardner, & Downey, 1988; St. Louis & Lass, 1980; Yaruss, 1999) and presentations at the annual ASHA conventions (e.g., Campbell, Hill, Yaruss, & Gregory, 1996; Chapman & Keintz, 1996, 1998; Kuster et al., 2000), as well as in the topic of the 2001 leadership conference of ASHA special interest division for fluency and fluency disorders (SID-4), which focused specifically on improving academic and clinical education in fluency disorders. There are a number of potential explanations for this apparently growing interest in graduate education in fluency disorders. One is the repeated finding that both student clinicians and experienced speech–language pathologists are less comfortable working with stuttering than other communication disorders (e.g., Brisk et al., 1997; Kelly et al., 1997; Mallard et al., 1988; St. Louis & Durrenberger, 1993). Many students and clinicians also appear to hold common misconceptions about stuttering or harbor negative attitudes about people who stutter (e.g., Cooper & Cooper, 1985, 1996; Lass, Ruscello, Pannbacker, Schmitt, & Everly-Myers, 1989). Previously existing concerns about clinicians’ comfort with stuttering have been compounded by concerns about the elimination of specific training requirements in fluency disorders for graduate students pursuing the ASHA certificate of clinical competence in speech–language pathology (CCC-SLP). Prior to the implementation of the current standards (ASHA, 1993), students were required to obtain at least 25 hours of clinical practicum with people who stutter. Although this amount of training can be considered minimal, it was the same as the amount of experience required in other disorder areas, and it gave students some exposure to diagnosis and treatment in fluency disorders. Currently, however, training programs are not required to provide specific experience with the traditional disorder areas of voice, fluency, articulation, and language. Instead, programs must focus training on “speech disorders” (which includes stuttering among other areas) or “language disorders” for pediatric and adult populations. This change provided needed flexibility for programs that had been having difficulty meeting the 25 hours requirement, particularly given the expanding scope of

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practice within the field. Still, the change focused renewed attention on the training students receive, and how this training may be related to students’ comfort with disorder areas such as stuttering. In an attempt to gather information about student training in the area of fluency disorders, Yaruss (1999) presented a survey of coursework and clinical experiences required by ASHA-accredited graduate programs. This survey, distributed in 1997, examined factors such as “(a) the size of the program (both in terms of the number of students and the number of academic and clinical faculty), (b) the amount of required and elective coursework in fluency disorders available to students, (c) the degree to which this coursework focuses on theoretical background or clinical application, (d) whether the coursework involved practical or lab sessions, (e) whether assessment of students’ performance involved competency-based testing, (f) the number of hours of clinical practicum training obtained by most students, (g) the level of clinical and research expertise of the academic faculty teaching the courses in fluency, (h) the level of clinical experience of the clinical faculty providing supervision in fluency, and (i) the nature of any changes in program requirements following the 1993 change in ASHAs regulations.” (Yaruss, 1999, p. 173). The survey was sent to 239 ASHA-accredited graduate training programs, and a total of 134 programs responded (overall response rate from initial and follow-up mailings = 56%). Results from the 1997 survey indicated that 75% of responding programs had at least one required course devoted to fluency disorders, with 29% offering at least one elective course. Overall, 18% of responding programs indicated that it was possible for a student to graduate without taking any classes specifically devoted to fluency disorders. Clinical experience was required by fewer programs, with more than 50% of programs reporting that no clinical practicum hours in fluency disorders were required. No relationships were found between the amount of academic and clinical education in fluency disorders and program size, measured either in terms of the number of students or the number of faculty, suggesting that educational requirements in fluency disorders are not simply related to the availability of resources. Finally, one-half of responding programs indicated that they reduced or eliminated their academic and clinical requirements following ASHA’s elimination of specific standards in fluency disorders in 1993. By themselves, these findings are a cause for some concern, given prior negative reports about clinicians’ comfort and competence with fluency disorders. Compounding these concerns were post-hoc analyses suggesting that the respondents to the 1997 survey tended to be those with a particular interest in the area of fluency disorders (as indicated by membership in ASHA’s SID-4 or the International Fluency Association), suggesting that the 105 programs that did not respond to the survey may have training requirements in fluency disorders that were even less rigorous.

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Although the 1997 survey yielded important information about the amount of training that is provided in graduate programs across the country, there are a number of difficulties with the survey that hamper further interpretation of the findings. First, although an attempt was made to elicit responses from all ASHA-accredited training programs, only slightly more than half of the programs responded to the survey. As a result, it is not entirely clear how representative the findings are, and as noted above, there is some indication that there may have been a responder bias toward greater representation by programs with faculty members who had a vested interest in maintaining training requirements in fluency disorders. Second, because the specialty recognition program was still in development at the time of the 1997 survey, it was difficult to assess this possible responder bias based on whether or not the faculty were Board Recognized Specialists in Fluency Disorders. Now that the inaugural cadre of specialists has been certified, it would be helpful to repeat the survey to assess more directly the degree of interest in fluency disorders among the individuals who responded to the survey, and whether interest in fluency disorders had any relationship to the academic or clinical requirements in the program. Third, the results from the 1997 survey presented only a snapshot of the training requirements across the field. The findings cannot tell us if the training requirements at graduate programs are relatively stable over time, or if there is a trend toward increased or decreased requirements as the scope of practice within the field continues to broaden, or as the specialties represented within a program’s faculty change. Understanding any trends is critical to formulating an appropriate response for ensuring appropriate training in fluency disorders for graduate student clinicians. Fourth, some of the questions from the initial survey sought only general information about factors affecting training in fluency disorders. If we are to more fully document the current status of academic and clinical education to support further research as requirements change, then more detailed information is necessary. Fifth, the survey asked only general questions about whether programs made changes in their academic or clinical education based on ASHA’s 1993 change in the training standards. Specific information about the nature of those changes was gleaned from comments made by the respondents, so it is clear that the initial information that was obtained cannot be representative of the overall pattern of changes that were implemented. Thus, further information about the nature of past changes will be necessary. Finally, since the 1997 survey was completed, ASHA has released a new set of academic and clinical education requirements for the CCC, to take effect 1 January 2005 (ASHA, 2000). The new CCC guidelines do not specify requirements about the courses or clinical experiences students must complete, but instead, focus on the competencies students are expected to achieve. Examples of these competencies include: the ability to demonstrate specific knowledge about the nature, assessment, and treatment of a variety of disorder areas (including fluency disorders), as well as knowledge about research, ethics, and professional issues. This focus on the outcome rather than the process of preparing competent clinicians may be seen as a positive step for improving students’ training; however, it still

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raises questions about how graduate students will receive the training they need if programs do not require coursework or clinical experiences in fluency disorders. In order to assess the future impact of the new standards on training programs’ educational requirements, therefore, it will be necessary to have a more thorough understanding of the requirements that are currently in place. Furthermore, if we are to understand the rationale behind any changes that are enacted, it will be useful to gather information from training programs as they are planning and preparing to implement changes to their curricula and training programs. In sum, as the field prepares to implement the new training standards for the ASHA CCC, it will be useful to have considerably more detailed information about the education in fluency disorders that is currently provided by ASHA-accredited graduate programs, as well as more specific information about how programs have changed their requirements over the past several years. The 1997 survey gathered some of this information; however, more information is needed. Accordingly, the purposes of this follow-up study were: (a) to collect additional information about the academic and clinical education in fluency disorders that is provided in ASHA-accredited graduate training programs and (b) to compare the findings to the 1997 results in an attempt to identify any trends in as programs prepare to implement the 2005 standards.

2. Methods 2.1. Questionnaire This study involved a two-page questionnaire (shown in Appendix A) that was sent to all 256 training programs that were accredited by ASHA in October 2000. The present survey was similar to the original 1997 survey, in that data were collected in the following categories: (a) demographic information (e.g., number of students and faculty), (b) academic coursework (e.g., number and nature of classes), (c) individual(s) teaching the academic coursework (e.g., research and clinical experience with fluency disorders), (d) clinical practicum experiences (e.g., number of students obtaining practicum), (e) individual(s) supervising the clinical practicum experiences (e.g., experience with fluency disorders), (f) changes in training in response to the revisions to the CCC standards. The present survey differed from the initial survey, however, in that it collected more specific information in each of these categories, such as the number of credit hours assigned to each course in fluency disorders, whether the faculty members are members of ASHA’s SID-4 or hold specialty recognition, the average number of hours of clinical practicum students obtain, and more detailed information about changes associated with the 1993 and 2005 revisions to the CCC standards. As a result, the current survey was sufficiently similar to the 1997 survey in order to allow comparisons to be made across the two samples, while still collecting information that was lacking in the original questionnaire. (Note that direct comparison

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between the 1997 dataset and the present data is not possible since programs were not required to identify themselves in either the initial or follow-up surveys.) 2.2. Respondents Contact names and addresses for accredited programs were obtained from the ASHA website, and recipients were sent a packet containing a cover letter, the questionnaire, and a return envelope. The purpose of the cover letter was to explain the background and rationale for the study and to assure respondents that individual programs would not be identified in the results. In fact, as with the 1997 survey, respondents were not required to disclose the name of their institution. This was done to minimize the chance that programs might refuse to respond to the survey due to concerns that their training requirements would be singled out in resulting publications. Following the initial mailing of this follow-up survey, in November 2000, 121 responses were received (response rate = 47.3%). This initial response rate is very similar to that for the original survey conducted in 1997, in which 122 out of 239 questionnaires were returned (initial response rate = 51.0%). In an attempt to increase the overall response rate (one of the goals of this follow-up study), a second mailing was sent out to 167 programs in February 2001. (The second mailing excluded programs that had voluntarily indicated the name of their institution in their response.) An additional 38 programs returned the survey, yielding a total number of programs responding equal to 159, and a total overall return rate equal to 67.4% — an increase of 20% compared to the 56.1% return rate for the 1997 survey. As is common with survey research of this kind, some respondents did not provide answers to all of the questions on the survey. Thus, the total number of responses for some questions was less than 159. To facilitate interpretation in the results presented below, the total number of programs responding to each item is presented along with the analyses.

3. Results 3.1. Program size and duration A total of 135 programs provided information about the number of undergraduate students enrolled in the major, with the average size of the undergraduate program equaling 101.5 students (S.D. = 62.8, range = 6–350). For the 154 programs that provided information about the number of students in the graduate program, the average size of the graduate program was 54.6 students (S.D. = 36.3, range = 6–400). A total of 100 programs provided information about the number of part-time faculty, with an average number of part-time faculty members of 4.0 (S.D. = 3.6,

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range = 0–20). The 131 programs that provided information about full-time faculty indicated an average number of full-time faculty of 9.6 (S.D. = 6.3, range = 3–60). The vast majority of programs (134 out of 149 responding, or 89.9%) indicated that their program is on a semester system, with an average program length for the Master’s degree of 5.2 semesters (S.D. = 1.0; range = 3–10). The remaining programs (15 out of 149 responding, or 10.1%) reported using a quarter system, with an average program length for the Master’s degree of 7.3 quarters (S.D. = 1.0; range = 4–8). 3.2. Academic education 3.2.1. Required and elective coursework All 159 responding programs provided information about required and elective coursework in fluency disorders. A total of 123 programs (77.4%) indicated that they have a required graduate course exclusively devoted to fluency disorders, and that the required courses are worth, on average, three credits (S.D. = 0.4, range = 2–5). Also, 53 programs (33.3%) reported that they have an elective graduate course exclusively devoted to fluency disorders, and that the elective courses are worth, on average, 2.8 credits (S.D. = 0.6; range = 1–5). Respondents indicated that approximately 50% of students take these elective courses (S.D. = 31.8%; range = 5–100%). A total of 23 programs (14.5%) reported both a required and an elective course, and 55 programs (35.7%) reported that stuttering is covered as part of other courses. Still, this coverage was often provided in courses on neurogenic disorders or clinical methods, and the percent of class time spent on fluency disorders ranged from 0 to 50%. Only 6 programs (3.8%) reported neither a required nor an elective class in fluency disorders. Overall, these figures are quite similar to those reported in the 1997 survey, in which 75% of programs reported a required course, 29% reported an elective course, and 5% reported neither an elective nor a required course. In this survey, a total of 36 programs (22.6%) indicated that it is possible for a student to graduate without taking any courses exclusively devoted to fluency disorders, a figure that is slightly higher than the 17.8% reported in the 1997 survey. 3.2.2. Nature of academic coursework When asked about the nature of the academic education in the required and elective courses on fluency disorders, respondents indicated that theoretical issues, such as the etiology of stuttering, occupied an average of 40.2% of class time (S.D. = 17.6%; range = 0–100%), clinical issues; such as diagnosis and treatment, occupied an average of 58.6% of class time (S.D. = 17.3%; range = 0–100%), and other issues; such as professional relations and specialty recognition, occupied an average of 1.2% of class time (S.D. = 4.4%; range = 0–25%). Viewed differently, 42 programs (27%) reported a roughly equal balance between theoretical issues and clinical application, 24 programs (15%) reported an emphasis

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on theoretical issues, and 91 programs (58%) reported an emphasis on clinical application. These figures indicate a slight shift toward a greater emphasis on clinical application when compared to the 1997 survey, when 59% of programs reported an equal split between theory and clinic, 11% reported an emphasis on theoretical issues, and 30% reported an emphasis on clinical applications. A total of 114 respondents (71.7%) indicated that courses include some sort of laboratory or practical sessions, a figure that is higher than the 58.5% reported in the 1997 survey. Only 46 programs (28.9%) indicated that courses require any kind of competency-based testing to evaluate students’ performance, a figure that is similar to the 30.5% reported in the 1997 survey. 3.2.3. Individuals teaching courses When asked about the individuals teaching the courses in fluency disorders, 121 programs (out of 152 responding, 79.6%) indicated that courses were taught by tenure-track faculty, and 21 (13.2%) indicated that courses were taught by adjunct or part-time faculty. These findings indicate a reduction in the number of full-time faculty teaching fluency disorders compared to the 1997 data, when full-time faculty taught 89% of the classes and adjunct or part-time faculty taught only 6% of classes. Consistent with the findings from the 1997 survey, nearly all programs indicated that the person teaching the fluency courses holds the ASHA CCC (138 out of 140 responding, or 98.6%). Most also reported membership in ASHA’s SID-4 (99 out of 149 responding, or 66.4%). Only 55 (out of 149 responding, or 36.9%) reported they have received the Certificate of Specialty Recognition in Fluency Disorders, though 90 (out of 155 responding, or 58.1%) reported that fluency was their primary area of academic or clinical expertise (a figure somewhat lower than the 65% found in the 1997 data). In addition, 75% of programs rated their faculty members’ previous clinical experience with stuttering to be extensive (rating 4 or 5 on a 5-point scale) and 58% rated their current clinical experience to be extensive. Only 32% of responding programs rated their faculty members’ research experience with stuttering to be extensive, a figure slightly lower than the 37% found in the 1997 data. 3.3. Clinical education 3.3.1. Clinical practicum experiences Out of 150 programs that provided information about required practicum experiences, 55 (36.7%) reported that clinical experience is required in the assessment of fluency disorders, and 54 (36.0%) reported that experience is required in the treatment of fluency disorders. These figures represent a decrease from the findings of the 1997 survey, when 44% of programs required experience with assessment and 49% required experience with treatment. Overall, 97 programs (out of 149 responding, or 65.1%) reported that it is possible for students to graduate without any clinical experience in stuttering, an apparent increase from the 59% in the 1997 survey.

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The 120 programs that provided information about the clinical practicum they offer in the assessment of fluency disorders reported an average of 7.8 hours of assessment experience (S.D. = 6.7%, range = 0–35%), with 58.2% of this time spent with children and 41.8% spent with adults. Of the 136 programs that provided information about where students obtain the majority of their clinical practicum hours in assessment, 81 (59.6%) reported that the majority of the practicum is obtained in a university clinic, 47 (34.6%) reported that the majority of the practicum is obtained in an externship outside the university clinic, and 8 (5.9%) indicated a relatively even split between in-clinic and out-of-clinic experiences. The 117 programs that provided information about the clinical practicum they offer in the treatment of fluency disorders reported an average of 16.7 hours of treatment experience (S.D. = 9.2, range = 0–50), with 58.8% of the time spent with children and 41.2% spent with adults. Of the 134 programs that provided information about where students obtain the majority of their clinical practicum hours in assessment, 74 (55.2%) reported that the majority of the practicum is obtained in a university clinic, 54 (40.3%) reported that the majority of the practicum is obtained in an externship outside the university clinic, and 6 (4.5%) indicated a relatively even split between in-clinic and out-of-clinic experiences. 3.3.2. Individuals supervising clinical practicum experiences Fifty programs (31.6%) indicated that the person who typically supervises the clinical practicum is the same as the person who teaches the academic coursework. Of the remaining programs, 96 provided information about the individuals supervising the students’ clinical practicum experiences, with 48 programs (50%) indicating that the supervisor views fluency disorders as a primary area of expertise, a figure considerably lower than the 73% found in the 1997 survey. Only 36 out of 96 programs (37.5%) reported that the supervisor is a member of ASHA’s SID-4, and 19 out of 91 programs (20.9%) indicated that the supervisor has received the Certificate of Specialty Recognition in Fluency Disorders. A total of 14 programs (8.8% of the entire sample) indicated that both the academic and clinical faculty members held specialty recognition. Finally, 53% of programs indicated that their supervisors’ previous clinical experience in fluency disorders is extensive (rating 4 or 5 on a 5-point scale), and 49% indicated that their supervisors’ current clinical experience is extensive, figures which are lower than the 68% found in the 1997 survey. 3.4. Relationship between education and program size To evaluate whether the academic and clinical education requirements of the training programs was related to the size of the program, programs were divided into small, medium, and large sizes based on (a) the number of graduate students enrolled in the program, and (b) the total number of faculty in the program (including part-time and full-time faculty). Small programs were defined as those at or below the 33rd percentile and larger programs were defined as those at or above

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the 67th percentile. A Chi-square analysis revealed no significant relationships between the number of graduate students and the likelihood that a student could graduate without any academic coursework (χ 2 = 1.42, df = 2, P = 0.49) or clinical practicum (χ 2 = 0.32, df = 2, P = 0.85). Similar negative findings were found between the number of faculty in the program and the likelihood that a student could graduate without any academic coursework (χ 2 = 1.13, df = 2, P = 0.57) or clinical practicum (χ 2 = 1.46, df = 2, P = 0.28). These findings are consistent with the results of the 1997 survey, which also found no relationships between program size and training requirements. 3.5. Changes in program requirements 3.5.1. Following 1993 changes to CCC standards Overall, 90 programs (57.0%) reported changes in their academic and clinical education requirements following ASHA’s 1993 modifications to the standards for the CCC, a figure slightly higher than the 50.4% that reported changes in the 1997 survey. Of the 90 programs that reported changes, 23 (25.6%) indicated that they reduced course requirements (e.g., by eliminating the stuttering course or making it an elective, or by reducing the number of credit hours assigned to the class from 3 to 2 credits). Three programs (3.3%) indicated that they increased course requirements (e.g., by making an elective course a requirement or increasing the number of credits assigned to a course). Changes in the clinical practicum were more common: of the 90 programs that reported changes, 86 (95.6%) reported reductions in the clinical practicum requirements, and none reported increases in the clinical practicum. Both of these figures represent notable increases from the results of the 1997 survey, in which 9% of programs reported a change to the academic coursework and 63% of programs reported changes to the clinical practicum. This finding suggests either that the initial survey underestimated the magnitude of the reductions in training that followed the implementation of the 1993 standards or that reductions in training requirements may have continued to occur since the time of the 1997 survey. 3.5.2. In preparation for 2005 changes to CCC standards Several programs indicated that their faculty is still reviewing the new standards and many respondents simply indicated that they did not yet know whether changes would occur. Still, at this early stage of planning, 35 programs (22.3%) indicated that they anticipate changes in the academic or clinical training in fluency disorders in preparation for ASHAs new 2005 standards for the CCC. Of those, 22 (62.9%) expect further reductions in academic requirements (e.g., reducing the credit hours for the fluency class), and 18 (51.4%) expect further reductions in clinical requirements. A few respondents commented that they do not anticipate any further reductions in their academic and clinical educational requirements in fluency disorders since they have already eliminated all requirements. A few other programs

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indicated that they anticipated increases in academic (5 programs, or 14.3%) or clinical training (6 programs, or 17.1%), though no specific details were provided. Finally, several respondents noted concern about the future of fluency disorders within the field as a whole and others indicated that the future of academic and clinical education within their department would depend upon whether they were able to replace a retiring faculty member with another individual with expertise in stuttering.

4. Discussion The purpose of this study was to provide information about the academic and clinical education in fluency disorders that is provided to students in ASHAaccredited graduate training programs. Results indicate that the majority of training programs do offer both required and elective courses in fluency disorders, and that many students take elective courses when they are available. Only 6 programs indicated that they offer no courses in fluency disorders at all, though several others indicated that their information about fluency disorders is provided in a class that addresses multiple topics. Nearly one-quarter of the programs that responded to this survey allow their students to graduate without taking courses in fluency disorders. Similarly, although clinical practicum may be available to students in many programs, the average number of hours of experience they receive is small, and nearly two-thirds of the responding programs allow students to graduate without any clinical practicum hours in fluency disorders. The amount of academic or clinical education provided by the training programs was not related to the size of the programs, measured either in terms of the number of students or the number of faculty, a finding which suggests that the amount of training is not simply associated with the amount of resources that are available. Overall, findings from the present study are consistent with the results of a similar survey conducted in 1997 (Yaruss, 1999), which also indicated that many graduate students in speech–language pathology do not receive very much training in the area of fluency disorders. In fact, a comparison of the two surveys reveals a number of trends. As shown Fig. 1, present findings suggest: (a) an increase in the number of programs that allow students to graduate without academic or clinical training in fluency disorders; (b) a reduction in the amount of assessment and treatment experience students are required to obtain; (c) a decrease in the number of full-time faculty members, and corresponding increase in the number of part-time or adjunct faculty members teaching courses in fluency disorders; and (d) a decrease in the number of faculty with extensive clinical and research experience in fluency disorders. These last two findings may reflect the number of faculty with expertise in fluency disorders who have retired, but who have not been replaced by new faculty with similar expertise. On the other hand, a comparison with the 1997 survey also indicates an increase in the number of programs

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offering practical or laboratory sessions associated with academic coursework, a trend which may help to improve education within the classroom setting even if the number of clinical experiences is reduced. In addition, there appears to have been an increase in the number of programs that emphasize clinical application in their graduate courses, as opposed to focusing primarily on theoretical issues and background. If confirmed, this trend would parallel a suggestion made by Quesal (2001) in a presentation at the SID-4 leadership conference aimed at improving academic and clinical education in fluency disorders. Of course, it is not possible to determine from these results whether this apparent trend represents a true change in the training provided to graduate students in our field, or whether the differences between the 1997 survey and the present survey are due to sampling differences or, perhaps, regression to the mean. As noted above, respondents were not required to identify their programs on the survey, in an attempt to reduce the likelihood that some individuals would not respond because of concerns that their program would be singled out or identified in the results. Thus, direct evaluation of changes within individual training programs is not possible, and it would be useful, in further studies of this kind, to be able to track changes in the requirements of specific training programs (e.g., through coding of response forms or other means of identifying responses). Still, given that the current analysis includes data from more than two-thirds of all ASHA-accredited training programs, combined with the fact that present results are largely replicate findings from the 1997 survey, it seems safe to conclude that the future of academic and clinical education in fluency disorders is in a precarious position. It is important to recognize that this investigation, like the original 1997 study, is affected by response bias. Although this survey had a notably higher overall response rate (67.4%) than the 1997 survey (56.1%), it is still likely that the individuals who took the time to complete the survey were those who were interested in fluency disorders and, in particular, the fate of academic and clinical education in fluency disorders in graduate training programs. Such a response bias is probably unavoidable for any study that depends upon participants to provide information by completing and returning a survey, and self-selection most certainly has an impact on the findings for this research. With the 1997 survey, the potential self-selection bias was demonstrated through a post-hoc analysis that examined the percentage of programs that had a faculty member belonging to ASHA’s SID-4 (61% in the 1997 survey) compared to the total number of programs that were represented in SID-4 (40% in the 1998 roster). A similar situation exists with the present dataset. According to the SID-4 roster dated 16 July 2001, which indicates a total of 699 division members, approximately 92 of the 259 programs that received this survey (36.5%) have at least one faculty member belonging to the special interest division. In contrast, 66.4% of programs that responded to the survey indicated that they have a faculty member belonging to the division, a figure that is 87% higher than the total percentage of programs represented in the division roster. Thus, the present results do appear to be affected by a response bias in which programs that

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do have a faculty member belonging to the division were more likely to respond than programs that do not. Of course, membership in a special interest division does not by itself suggest that a particular faculty member has expertise in fluency disorders; however, it does indicate a certain degree of interest and is therefore a relevant measure. The present study attempted to take the analysis of a potential response bias one step further by also considering whether the findings may have been affected by an over-representation of programs with a faculty member who holds the Certificate of Specialty Recognition in Fluency Disorders. This could not have been done with the 1997 data, because the specialty recognition program was still in the early stages of implementation at that time. At this point, however, it is possible to determine whether the responding programs were more likely to have a fluency specialist on the faculty. Although it is not entirely clear what impact a fluency specialist will have on a curriculum, is seems reasonable to assume that a Board Recognized Specialist in Fluency Disorders may serve as an advocate for retaining academic coursework or clinical practicum experiences in fluency disorders, even in the face of changing ASHA requirements. Indeed, a Chi-square test examining the relationship between the likelihood that a program would allow students to graduate without a class in fluency disorders and the presence of a fluency specialist on the faculty revealed that programs with a fluency specialist were significantly less likely to allow students to graduate without a class in fluency disorders (χ 2 = 5.04, df = 2, P = 0.025). Therefore, additional post-hoc analyses were undertaken to determine whether the responding programs were more likely to be those with a fluency specialist. A review of the list of Board Recognized Specialists in Fluency Disorders (available at: http://www.ausp.memphis.edu/sbfd), dated 1 May 2001 (the most current list as of this writing) reveals that roughly 87 out of the 259 ASHA-accredited training programs that received this survey (33.6%) have at least one fluency specialist on the faculty. (The total number of fluency specialists at that time was 296.) Of the programs that responded to this survey, however, 60 programs reporting either an academic or a clinical faculty member with specialty recognition (40.2%, a figure that is 20% greater than the overall percentage of programs that have a fluency specialist on faculty). In other words, programs with a fluency specialist were somewhat more likely to respond to this survey than programs without a fluency specialist. Consideration of the raw numbers makes the selection bias in these data even more apparent, for 69% of the programs with a fluency specialist (60 out of 87) responded to the survey, whereas only 51% of those programs without a fluency specialist responded (88 out of a total of 173 ASHA-accredited programs without a specialist). Thus, it appears that the data in this survey are affected by self-selection bias resulting in over-representation of programs with faculty members with expertise in fluency disorders and, perhaps, more rigorous training standards in fluency disorders. Of course, it is impossible to determine, with certainty, the training requirements of those programs that did not respond to the survey; however, it seems likely that many

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of those programs, like many of the programs without a fluency specialist that did respond to this survey, may have fewer requirements in the area of fluency disorders. Finally, the present survey attempted to extend the findings from the original 1997 survey by gathering additional details about changes in academic and clinical training requirements following ASHA’s 1993 revisions to the CCC standards, as well as some preliminary information about preparations for the new 2005 standards. More than half of the programs reported that they did make changes in their academic or clinical training requirements in 1993. Many of these programs indicated that they had eliminated coursework requirements or changed required courses to electives. In addition, several programs indicated that they reduced the number of credit hours assigned to the class, for example, by turning a 3-credit class into a 2-credit class. Although individuals interested in preserving academic training in fluency disorders would no doubt find this to be preferable to having a program eliminate a class outright, it is still worth noting that 2-credit graduate courses do not presently meet the requirements established by the specialty recognition board for fluency disorders. Thus, students who complete their training at programs that offer only a 2-credit graduate course will be ineligible for specialty recognition unless they earn an additional graduate credit in fluency disorders. Unfortunately, the question regarding changes in program requirements following the implementation of the 1993 standards was mistakenly formatted on the present survey sheet. The question used a checkbox to indicate whether there were changes in training requirements, as opposed to a “Yes/No/No answer” format. Because of this formatting error, it is not possible to determine whether an empty checkbox meant “no changes” or simply “no answer”, so the results for this question may actually underestimate the true number of programs that instituted changes in 1993. (Indeed, this seems likely, given the fact that nearly two-thirds of programs now allow students to graduate without clinical practicum in fluency disorders, something that would not have been allowed under the pre-1993 guidelines.) The same problem exists for the question about changes in preparation for the 2005 guidelines. Not surprisingly, however, many respondents stated that their programs are still working on the changes in curriculum and clinical training that will be needed in order to address the new ASHA training standards. Although the 2005 standards do not specify the amount of clinical or academic training students should receive in the area of fluency disorders, it is possible that the new guidelines might lead to alternative models of training due to the requirement that student clinicians be able to demonstrate competency in the area of fluency disorders. At present, however, given the fact that only one-third of the responding programs indicated that they use any sort of competency-based testing in their courses on fluency disorders, it appears that many programs have a considerable amount of work before them as they prepare for the 2005 standards. Because the training standards have yet to take effect, this situation is one that is still developing and unfolding. In order to fully evaluate the impact of

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ASHA’s changes in the CCC standards, it will be necessary to conduct further research on the training that is required by graduate programs as these changes are planned, implemented, and evaluated. Combined with the results from the 1997 survey, the present findings provide a solid basis for such comparisons in future research. In sum, results from this study highlight the fact that many students do not receive adequate training in the area of fluency disorders. Combined with the results from the 1997 survey, present findings suggest a trend toward fewer required classes in fluency disorders taught by less experienced faculty, fewer clinical hours in the assessment and treatment of fluency disorders guided by less experienced supervisors, and a greater likelihood that students can graduate without any coursework or clinical practicum in fluency disorders. There are many potential explanations for why these changes have occurred in our training programs. The most obvious explanation is the fact that programs reduced their coursework and clinical experience because ASHA reduced the requirements in 1993. Given the multiple pressures on training programs to provide education across the breadth of this expanding field with increasingly limited resources, it is not surprising that they would eliminate requirements in those areas where training is not required. Still, it is likely that other factors played a role in these changes as well, such as the availability of clients or faculty (something that the present findings suggest may also be changing). Additional research will be necessary to determine if the 1993 change in the ASHA standards was indeed the reason for reductions in training requirements and, what the specific impact of the 2005 standards will be. Similarly, it will be helpful, in future research, to explore what factors caused some programs to retain their coursework and clinical training requirements in fluency disorders even after the ASHA standards were changed. If results of such research indicate that there is a direct relationship between the ASHA standards and the academic and clinical education provided by training programs, then it may be time to more critically examine the impact that these reductions in training requirements have on clinicians’ ability to work with people who stutter. The same concern might also be raised for other so-called “lower-incidence” communication disorders, such as voice disorders. Specific training requirements for voice disorders were also eliminated with the 1993 change in ASHA standards; however, at present, little information is available regarding the amount or type of academic and clinical education in voice disorders that is provided at ASHA-accredited training programs. Given the expanding scope of practice in the field, however, it is reasonable to assume that the situation is similar to that seen in fluency disorders. Even though the scope of practice has expanded dramatically, it is still critical that we provide adequate training in specific disorders that make up the core of this field. Given the complexity of the stuttering disorder and the repeated finding that many practicing clinicians already lack sufficient comfort and competence with fluency disorders, it would seem that more training and

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experience, not less, is needed to prepare clinicians to help people who stutter. Present results suggest that the field does not appear to be headed in this direction, at least as far as the training that is provided in graduate programs is concerned. Given that it is highly unlikely that ASHA will reinstate educational or clinical requirements in fluency disorders or other specific disorder areas, training programs, and indeed, the profession as a whole, must work to identify alternate ways of preparing student clinicians to appropriately and effectively evaluate and treat fluency disorders. Examples include an increase in the availability of post-graduate continuing education courses or in-service presentations on fluency disorders (cf. Sommers & Caruso, 1995), increased partnership with organizations such as the Stuttering Foundation of America (SFA) and National Stuttering Association (NSA) for providing ongoing education of speech–language pathologists who may be less comfortable with their skills for helping people who stutter, an increased number of activities sponsored by SID-4 (such as the newly created fluency “boot camps”), and, ultimately, increased participation in the specialty recognition program by clinicians with an interest in fluency disorders. If such efforts are not undertaken, and if the apparent trends identified in this study continue, then it is likely that the number of clinicians who are qualified to help people who stutter will decrease even further. It is hoped that the results from this survey, and, in particular, the trends that are seen in the comparison with the 1997 findings, will contribute needed support to the growing effort to identify meaningful and appropriate ways to train graduate students — as well as practicing clinicians — about fluency disorders and to improve the quality of clinical services that is provided for people who stutter. Acknowledgments The authors are grateful to the faculty who completed the questionnaire and also to our colleagues in ASHAs Special Interest Division 4 who have taken up the challenge of improving academic and clinical training in fluency disorders. The authors also appreciate the assistance of Dana Knight and Patsy McMelleon in distributing the questionnaires and entering the data. Portions of this paper were presented at the 2001 ASHA convention in New Orleans, LA. This research was supported, in part, by an NIH Grant (R01 03810) to the University of Pittsburgh.

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Appendix A

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Appendix A (continued )

References American Speech–Language–Hearing Association (1993). Membership and certification handbook of the American Speech–Language–Hearing Association for speech–language pathology. Rockville, MD: American Speech–Language–Hearing Association. American Speech–Language–Hearing Association (2000). Standards and implementation for the certificate of clinical competence in speech–language pathology. Rockville, MD: American Speech–Language–Hearing Association. Brisk, D. J., Healey, E. C., & Hux, K. A. (1997). Clinicians’ training and confidence associated with treating school-age children who stutter: a national survey. Language, Speech, and Hearing Services in Schools, 28, 164–176.

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Campbell, J. H., Hill, D. G., Yaruss, J. S., & Gregory, H. H. (1996). Integrating academic and clinical education in fluency disorders. Invited seminar presented at the annual convention of the American Speech–Language–Hearing Association, Seattle, WA. Chapman, L., & Keintz, C. (1996). Student clinical experience: is it adequate in all disorder areas? Presentation at the Annual Convention of the American Speech–Language–Hearing Association, Seattle, WA. Chapman, L., & Keintz, C. (1998). Perceptions of newly certified SLPs concerning graduate clinical preparation. Presentation at the Annual Convention of the American Speech–Language–Hearing Association, San Antonio, TX. Cooper, E., & Cooper, C. S. (1985). Clinician attitudes towards stuttering: a decade of change (1973–1983). Journal of Fluency Disorders, 10, 19–33. Cooper, E., & Cooper, C. S. (1996). Clinician attitudes towards stuttering: two decades of change. Journal of Fluency Disorders, 21, 119–136. Kelly, E. M., Martin, J. S., Baker, K. E., Rivera, N. I., Bishop, J. E., Krizizke, C. B., Stettler, D. S., & Stealy, J. M. (1997). Academic and clinical preparation and practices of school speech–language pathologists with people who stutter. Language, Speech and Hearing Services in Schools, 28, 195–212. Kuster, J. K., Cordes, A. K., Guitar, B., Hood, S. B., Quesal, R. W., Bernstein Ratner, N., & Yaruss, J. S. (2000). Educators’ forum: academic training in stuttering and other fluency disorders. Seminar presented at the Annual Convention of the American Speech–Language–Hearing Association, Washington, DC. Lass, N. J., Ruscello, D. M., Pannbacker, M. D., Schmitt, J. F., & Everly-Myers, D. S. (1989). Speech–language pathologists’ perceptions of child and adult female and male stutterers. Journal of Fluency Disorders, 14, 127–134. Leith, W. R. (1971). Clinical training in stuttering therapy: a survey. Journal of the American Speech and Hearing Association, 13, 6–8. Mallard, A. R., Gardner, L. S., & Downey, C. S. (1988). Clinical training in stuttering for school clinicians. Journal of Fluency Disorders, 13, 253–259. Quesal, R. W. (2001). How do students learn if clients aren’t there? Presentation to the Seventh Annual American Speech–Language–Hearing Association Special Interest Division 4 Leadership Conference, Toronto, Ontario. St. Louis, K. O., & Durrenberger, C. H. (1993). What communication disorders do experienced clinicians prefer to manage? ASHA, 35, 23–31. St. Louis, K. O., & Lass, N. J. (1980). A survey of university training in stuttering. Journal of the National Student Speech Language Hearing Association, 10, 88–97. Sommers, R. K., & Caruso, A. J. (1995). In-service training in speech–language pathology: are we meeting the needs for fluency training? American Journal of Speech–Language Pathology, 4(3), 22–28. Yaruss, J. S. (1999). Current status of academic and clinical education in fluency disorders at ASHA-accredited training programs. Journal of Fluency Disorders, 24, 169–184.

CONTINUING EDUCATION QUESTIONS 1. The purpose(s) of the present study was/were to: a. evaluate the current academic and clinical education requirements in the area of fluency disorders at ASHA-accredited graduate institutions b. examine changes in training requirements at graduate programs that have occurred since ASHA changed the standard for the ASHA CCC in 1993 c. obtain preliminary information about changes that programs have planned for their training requirements as the new standards take effect in 2005

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2.

3.

4.

5.

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d. collect additional information about academic and clinical training to supplement data collected in a prior survey distributed in 1997 e. all of the above The methods of this study involved: a. a questionnaire sent to all undergraduate programs that have a major in communication science and disorders b. a questionnaire sent to all graduate programs that were accredited by ASHA as of October 2000 c. a questionnaire sent to all undergraduate and graduate programs in the United States that have a major in communication science and disorders d. a survey of syllabi of fluency courses at randomly selected training programs e. none of the above The present survey differed from the original (1997) survey in that it: a. collected more detailed information about programs’ training standards in a variety of categories b. sought more detailed information about whether academic or clinical faculty specialized in fluency disorders c. involved both interview and questionnaire-based data collection procedures d. (a) and (b) only e. (a), (b), and (c) Results of this survey indicate: a. the majority of programs do provide coursework in fluency disorders b. the majority of programs allow students to graduate without any clinical experience in fluency disorders c. the majority of programs do not provide coursework in fluency disorders d. (a) and (b) e. (b) and (c) Combined with the results of the 1997 survey (Yaruss, 1999), present findings indicate trends suggesting that: a. fewer programs are requiring courses in fluency disorders and fewer programs are requiring clinical experience in fluency disorders b. individuals teaching classes and supervising clinical practicum report less expertise in fluency disorders c. more programs maintaining the old 25 hour requirement for clinical experience in fluency disorders d. (a) and (b) e. (a), (b), and (c)