title: Non-pharmacological treatments for stuttering in children and adults: a systematic review and evaluation of clinical effectiveness, and exploration of barriers to successful outcomes.
abstract: BACKGROUND
  Despite many years of research, there is no certainty regarding the cause of stuttering. Although numerous interventions have been developed, a broad-based systematic review across all forms of intervention for adults and children was needed including views and perceptions of people who stutter.
  
  
  OBJECTIVE
  The aims of the study were to report the clinical effectiveness of interventions for people who stutter (or clutter), to examine evidence regarding the views of people who stutter and the views of professionals regarding interventions.
  
  
  METHODS
  A systematic review of quantitative and qualitative literature was carried out between August 2013 and April 2014. The following electronic databases were searched: (1) MEDLINE, (2) EMBASE, (3) The Cochrane Library (including The Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, Health Technology Assessment Database and NHS Economic Evaluations Database), (4) PsycINFO, (5) Science Citation Index, (6) Social Science Citation Index, (7) Cumulative Index to Nursing and Allied Health Literature, (8) ASSIA, (9) Linguistics and Language Behavior Abstracts, (10) Sociological Abstracts and (11) the EPPI Centre. Reference lists of included papers and other reviews were screened and also key journals in the subject area were hand-searched.
  
  
  METHODS
  The searches aimed to identify (1) evidence of clinical effectiveness in populations of pre-school children, school-aged children, adolescents and adults, and (2) data relating to perceptions of barriers and facilitators to intervention clinical effectiveness among staff and people who stutter. A metasynthesis of the two linked elements via development of a conceptual model was also carried out to provide further interpretation of the review findings.
  
  
  RESULTS
  A systematic search of the literature identified a large number of potentially relevant studies. Of these, 111 studies examining the clinical effectiveness of interventions, 25 qualitative papers and one mixed-methods paper met the criteria for inclusion in this review. Review of the effectiveness literature indicated evidence of positive outcomes across all types of interventions. Virtually all evidence we identified reported at least some positive effect for some participants. However, there was evidence of considerable individual variation in outcome for study participants. The qualitative literature highlighted the need for programmes to be tailored to individual need with variation at the levels of the intervention, the individual and interpersonal/social elements. Metasynthesis of the data highlighted the complexity of elements that need to be considered in evaluation of long-term impacts following stuttering interventions.
  
  
  CONCLUSIONS
  Around two-thirds of the studies were considered to be at higher risk of bias. The heterogeneous nature and variability in outcomes meant that we were unable to complete a meta-analysis.
  
  
  CONCLUSIONS
  Although much of the evidence we identified was from studies at risk of bias, it is suggested that most available interventions for stuttering may be of benefit to at least some people who stutter. There is a requirement for greater clarity regarding what the core outcomes following stuttering intervention should be and also enhanced understanding of the process whereby interventions effect change. Further analysis of those for whom interventions have not produced a significant benefit may provide additional insights into the complex intervention-outcomes pathway.
  
  
  BACKGROUND
  This study is registered as PROSPERO CRD42013004861.
authors.affiliation: School of Health and Related Research, University of Sheffield, Sheffield, UK.
authors.forename: Susan
authors.initials: S
authors.lastname: Baxter
authors.affiliation: School of Health and Related Research, University of Sheffield, Sheffield, UK.
authors.forename: Maxine
authors.initials: M
authors.lastname: Johnson
authors.affiliation: School of Health and Related Research, University of Sheffield, Sheffield, UK.
authors.forename: Lindsay
authors.initials: L
authors.lastname: Blank
authors.affiliation: School of Health and Related Research, University of Sheffield, Sheffield, UK.
authors.forename: Anna
authors.initials: A
authors.lastname: Cantrell
authors.affiliation: Department of Human Communication Sciences, University of Sheffield, Sheffield, UK.
authors.forename: Shelagh
authors.initials: S
authors.lastname: Brumfitt
authors.affiliation: School of Health and Related Research, University of Sheffield, Sheffield, UK.
authors.forename: Pamela
authors.initials: P
authors.lastname: Enderby
authors.affiliation: School of Health and Related Research, University of Sheffield, Sheffield, UK.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Goyder
mesh_terms: D006801:Humans; D013066:Speech-Language Pathology / Q000379:methods*; D013342:Stuttering / Q000628:therapy*; D016896:Treatment Outcome