E V I D E N C E - B A S E D P R A C T I C E IN S P E E C H L A N G U A G E P A T H O L O G Y : S C A L I N G UP Laura M . Justice T h e O h io S tate U niversity, C o lu m b u s , O h io , U n ite d States | A bstract E v id e n c e -b a s e d p ra c tic e is a process t o w h ic h clinical professionals a d h e re w h e n m a k in g decisions c o n c e rn in g th e as­ sessm ent o r tr e a tm e n t o f a g iv e n c o n d itio n . W ith in th e fie ld o f s p e e c h -la n g u a g e p a th o lo g y , it is in c re a s in g ly a d v o c a te d as b est p ractice. As o u r profession seeks to tra n s fo rm its e lf fro m o n e th a t is p rim a rily c ra ft-b a s e d to o n e th a t relies on e v id e n c e -b a s e d processes, it m u s t d e v e lo p a n d im p le m e n t a series o f structures th a t w ill fo s te r th is tra n s fo rm a tio n .T h is a rtic le describes th re e specific structures th a t are in creasin g ly a v a ila b le w ith in th e f ie ld o f s p e e c h -la n g u a g e p a th o lo g y in th e U n ite d States to g u id e tra n s fo rm a tio n o f th e profession: system atic rev iew s an d m e ta -an alyses, tr e a tm e n t studies, and clearin g h o u ses. W ith o u tth e s e stru ctu ral su p p o rts, it is u n lik e ly th a t e v id e n c e -b a s e d p ra c tic e c a n b e scaled u p in a w a y th a t has p o sitive im p a c ts o n practice. Keywords: e v id e n c e -b a s e d p ractice, system atic rev iew , m eta-analysis. Evidence-based practice is a process to which clini­cal professionals adhere when making decisions concerning the assessment or treatment o f a given condition. This process involves careful consideration and integration o f various types o f evidence so that the most effective solution can be identified; these types o f evidence include, minimally: (1) clinical expertise, (2) patient values and perspectives, and (3) best available scientific evidence (Sackett, Rosenberg, Gray, Haynes, 8c Richardson, 1996; Sackett, Straus, Richardson, Rosenberg, 8c Haynes, 2000). Evidence-based practice is recommended for use not only by speech-language pathologists, but also those involved with clinical decision-making in medicine (called evidence- based medicine; Evidence-Based M edicine W orking Group, 1992), nursing (Porter-O ’Grady, 2 0 0 7 ), psychology (Spring, 2 0 0 7 ), physical therapy (Cibulka 8c Aslin, 2 0 0 1 ), and special education (C ook 8c Shirmer, 2 0 0 6 ), among others. Regard­ less o f one’s discipline and, by consequence the nature and impact o f the decisions to be made, the process o f evidence- based practice is largely identical regardless o f whether one is selecting a treatment regiment for high blood pressure, for clinical depression, for stuttering, or for reading disability. As members o f the speech-language pathology community, it can be particularly insightful to examine the structures being put into place in other professions - medicine and education, for instance - as we transform our profession to ­ wards one that is evidence-based. I f we look to the larger literature on evidence-based prac­ tice, it is evident that all professions seeking transformation from craft-based to evidence-based clinical decision-mak­ ing models are in the process o f designing and implement­ ing complex types o f structures to not only ease this transfor­ mation but to make it even possible in the first place; some professions are much further along than others. B y struc­ tures, I am referring to tangible items and tools that must be developed to allow a profession to become more embedded in evidence. These structures include, for instance, provid­ ing guidelines to clinicians as to how to formulate well-built clinical questions (Schlosser, Koul, 8c Costello, 2 0 0 7 ), devel­ oping consensus statements regarding how much and what type o f evidence is needed for a treatment to be “empiri­ cally validated” (Gersten, Fuchs, Compton, Coyne, G reen­ wood, 8c Innocenti, 2 0 0 5 ), and articulating the sequenced steps that clinicians must follow so that they might conduct their own critical appraisals o f the scientific literature (e.g., Fey 8cJustice, 20 0 6 ; Justice 8c Snell, 2 0 07). W ith in the field o f speech-language pathology, these and many other struc­ tures necessary for the successful transformation o f a profes­ sion to one that is evidence-based are in the process o f being developed and have not, to any large extent, yet been taken to scale. Nonetheless, all signs point to the scaling up o f evi­ dence-based practice in the near future given that many rel­ evant structures are being put into place. Evidence-Based Practice in the United States: Stru c­ tures Prom oting Scalability In this article, I discuss three specific structures that are increasingly available within the field o f speech-language pathology in the United States: systematic reviews and meta-analyses, treatment studies, and clearinghouses. These three structures are, in my opinion, necessary tools for clini­ cians to engage in evidence-based practice and for a field to successfully transform itself to one that is evidence-based; their increasing availability provide evidence o f the scaling up o f evidence-based practice. Systematic R ev iew s a n d M eta-analyses Historically, speech-language pathologists in the U n it­ ed States have used practice guidelines (also called clinical guidelines) to help them answer pressing clinical questions. Practice guidelines are statements developed by teams o f ex­ perts to guide practitioners in how to make decisions regard­ ing specific circumstance (Field 8c Lohr, 1990). Although they may be developed through a systematic process, prac­ tice guidelines do not typically involve a comprehensive re­ view o f the literature on a specific topic nor a critical analysis o f available statistical data; they may, as a result, offer flawed interpretations o f the literature that represent the biases o f Author Contact: Laura M . Justice, 356 Arps Hall, 1945 N H igh Street, The Ohio State University, Columbus O H 43210, United States E-mail: justice.57 @osu. edu THE S O U T H A F R IC A N J O U R N A L OF C O M M U N IC A T IO N D ISO RD ER S, V O L . 55 2 0 0 8 | 7 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) mnemonic training) with that o f other treatment approaches (visual imagery, executive strategy training), nor did it pro­ vide a summary o f the average strength o f effects associated with a specific training. I t may be that one approach has very strong effects compared to other approaches, but the qualitative systematic review does not involve this type o f analysis and therefore such interpretations are not possible. A unique strength o f the meta-analysis is in the statistical combining o f data across multiple studies and the resulting effect size estimates. For professions that are seeking transformation towards being evidence-based, an important recent event is the shift towards generation o f evidence-based systematic reviews and evidence-based clinical guidelines as replacements for traditional practice guidelines. These are similar to tradi­ tional practice guidelines in that they attempt to offer clini­ cians useable knowledge regarding a particular clinical prob- lem> but they are generated through a much more systematic the identified body o f work. A qualitative systematic review process than occurs with practice guidelines. The American does not involve statistical analysis o f the research findings Speech-Language-Hearing Association, in response to rec- aggregated across studies, whereas a quantitative systematic ommendations o f the Jo in t Coordinating Com m ittee on review - also called a meta-analysis - is a type o f quantita- Evidence-Based Practice (American Speech-Language- tive research design that involves statistically examining the Hearing Association, 2 0 05), has shifted from generating aggregated results o f a systematic review to determine the practice guidelines to evidence-based systematic reviews average level o f effects attributable to a specific independent and is in the process o f accepting nominations for topics to variable. The independent variable may involve treatment address. The first evidence-based systematic review has un- (e g , average effects attributable to receiving specific types dergone public comments and will be published in the near o f treatment), measurement (e.g., average diagnostic accu- future; it examines the accumulated literature on the efficacy racy o f specific types o f tests), and general aspects o f devel- o f constraint-induced language intervention for use in apha- opment or disability (e.g., average concurrent or predictive sia rehabilitation. The Academy o f Neurologic Com m unica- association between two aspects o f development, such as tion Disorders and Sciences (2001) also has embarked on reading skill and intelligence or language ability and history developing evidence-based practice guidelines relevant to o f otitis media). Typically, a meta-analysis reports average e f- management o f communication disorders in neurologically fe e t sizes associated with a specific treatment or measure that impaired individuals, to include traumatic brain injury, de­ ls created by combining and then averaging data provided in mentia, and aphasia, among others. each study in a set. A n effect size is, essentially, the strength In addition to these initiatives at the national level, it is o f an effect as represented in standard deviation units, typi- also relevant to note that several meta-analyses have been cally reported using Cohens d i or estimating differences be- produced in recent years that greatly benefit clinicians’ en- tween groups (e.g., for analyses o f variance), or percentage gagement in evidence-based practice. The results o f meta- o variance accounted for, reported using r2 for correlational analyses permit the speech-language pathologist to make data. There are guidelines available in the literature, the most more informed decisions about the benefits that can reason- commonly used being those o f C ohen (1988), that discuss ably be expected from a particular type o f treatment In the how to interpret effect size estimates so that one knows i f an area o f treatment, meta-analyses have studied general treat- average effect reported in a meta-analysis is small, medium, m ent effects for aphasia (Robey, 1998), child language disor- or large in size. M eta-analysis is most suitably applied when ders (Law, Garrett, & Nye, 2 0 04), communication problems there are a reasonable number o f studies available on a given associated with autism (Goldstein, 2 0 0 2 ), fluency disorders topic, as too few studies can bias the results o f a meta-analy- (Andrews, Guitar, & Howie, 1980), and attention problems sis m both positive and negative directions. associated with traumatic brain injury (Park & In g les, 2 0 01), l o successfully engage in evidence-based practice, cli- to name several. M ore specific aspects o f treatment have also nicians must have access to systematically conducted, val- been explored, such as the average effects associated with id systematic reviews o f the accumulated literature to date, particular treatment approaches (e.g., intratympanic gen- Qualitative systematic reviews can be particularly helpfiil for tamicin for M eniere’s Disease; Cohen-Kerem et a l , 2004- clinicians to understand what is known about a particular behavioral treatments for stuttering; Herder, Howard Nye’ mqm7 ‘ lnstance, Coelho, DeRuyter, and Stein & Vanryckeghem, 2006) or treatment contexts (e.g.fpull- (1996) provided a useful synthesis o f efficacious treatment out for inclusive models o f language intervention; M cG in ty approaches for cogmtive-communication impairments o f & Justice, 2 0 06). Table 1 lists several meta-analyses that are adults secondary to traumatic brain injury. This article sum- likely to be o f interest to clinicians. marized the results o f various approaches to treating this Meta-analyses are usefiil not only for estimating the ef- condmon, although it did not statistically compare the aver- fects o f specific approaches to treatment, they are also quite age effects associated with anyone treatment approach (e.g., important for demonstrating to the field where there are LAURA M . JUSTICE 8 | DIE SUID -AFR IKA AN SE TYDSKRIF VIR K O M M U N IK A S IE -A FW Y K IN G S , VOL. 5 5 ,2 0 0 8 those experts who are involved in generating the guidelines (W oolf, Grol, Hutchinson, Eccles, & Grimshaw, 1999). In the field o f medicine, experts express concerns that clini­ cians’ use o f practice guidelines can result in use o f “ineffec­ tive, harmful, or wasteful interventions” (W o o lf et a l, 1999 p. 329). As medicine and other professions, like speech-language pathology, seek to take evidence-based practice to scale, we see increased utilization o f alternatives to practice guidelines - the systematic review and the meta-analysis - that offer a more systematic and potentially less biased approach to ­ wards synthesizing available research literature for the clini­ cian. A systematic review is a scientific investigation o f the available literature on a given topic. The review is systematic because the individual(s) completing the review adheres to a rigorous and preplanned process for identifying potential research articles for inclusion, appraising these articles to identify key findings, and for synthesizing findings across R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) serious gaps in our knowledge. For instance, M cG in ty and Justice (2006) conducted a meta-analysis o f outcomes at­ tributable to various treatment contexts (e.g., classroom- based, pull-out) for children with language disorders; they identified only three studies to date that have explicitly ad­ dressed this issue. As this example shows, as the field o f speech-language pathology scales up evidence-based prac­ tice within the clinical realm, speech-language researchers must also ensure that the kinds o f studies they are conduct­ ing produce useable knowledge that contributes to timely and pressing issues within clinical practice. Treatm ent Studies Speech-language pathologists who engage in evidence- based practice will turn not only to meta-analyses for guid­ ance in decision-making but also to individual treatment studies. As noted earlier, a meta-analysis is really only use­ ful when there are enough studies in a given area that ag­ gregation o f findings is possible. However, in many areas o f practice there are far too few studies available on a given topic for a meta-analysis to be useful. For instance, the clini­ cian who works with an adolescent who stutters and wants to treat the child’s anxiety and embarrassment about speak­ ing publicly will find no meta-analysis available on this top­ ic (Yaruss & Pelczarski, 2 0 07). The clinician will then have to look towards individual treatment studies and examine these for guidance on a particular approach that appears to be efficacious. W h ile this seems straightforward, the field o f speech- language pathology is plagued by a paucity o f treatment studies. O ne recent study o f group-design treatment stud­ ies published in three flagship American journals in speech- language pathology (Language, Speech, a n d H earin g Services in Schools; Am erican J o u r n a l o f Speech-Language Pathology; Jo u r n a l o f Speech, Language, an d H earin g Research) found that only 52 such studies were published over a 10-year period - averaging about 5 studies per year (Justice, Nye, Schwarz, M cG inty, & Rivera, 12008). Given that these studies address a broad range o f treatment foci o f relevance to speech-lan- guage pathology (e.g., fluency, voice, language, speech, liter­ acy), it is clear that clinicians’ access to treatment research is inadequate for meeting the broad range o f clinical questions they encounter in everyday practice. As noted by members o f the American Speech-Language-Hearing Association, a consequence o f the field’s transformation to evidence-based practice is the urgent need for research that addresses press­ ing clinical questions (American Speech-Language-H ear- ing Association, 2 005). Some evidence suggests that the generally limited pro­ duction rate o f treatment research is on the brink o f change, and this is largely in response to shifts in the funding streams that support empirical research in speech-language patholo­ gy. The Institute o f Education Sciences, which funds the ma­ jority o f educational research in the United States, has dra­ matically shifted its funding priorities in the last five years to emphasize the production o f more useable knowledge. As a result, funds provided to researchers who study the effica­ cy and effectiveness o f specific interventions and treatments using randomized controlled trial (R C T ) research designs have greatly increased. M any o f these studies are o f direct relevance to speech-language pathologists, such as studies o f E V ID E N C E - B A S E D P R A C T IC E TH E S O U T H A FR IC A N J O U R N A L the efficacy o f various language curricula for children at-risk for academic difficulties (Justice, M ashburn, Pence, & W i g - gins, 2 0 0 8 ). The National Institutes o f Health - and particu­ larly the Institute that funds a great deal o f research relevant to speech-language pathologists, the National Institute on Deafness and O ther Communication Disorders (N ID C D ) - has recently reported its intent to prioritize funding for “patient-oriented research” over less clinically-relevant ba­ sic research. O ne particular funding mechanism available through N I D C D prioritizes treatment research through its emphasis on funding research that “translates basic research findings into clinical tools” (N ID C D , 2 0 07). Types o f re­ search activities supported through this funding mechanism include: (a) dosage studies, (b) intervention development studies, and (c) studies o f prevention programs. In light o f relatively stagnant levels o f funding for social and behavioral research within the United States and the increasingly com­ petitive nature o f research funding, it is likely that we will see more speech-language researchers shift their research towards more treatm ent-oriented work, thereby fostering an increase in the number o f treatment study publications. In ­ deed, members o f the American Speech-Language-Hear- ing Association (2005) have specifically recommended an increase in the conduct o f randomized controlled trials by researchers in speech-language pathology. A n important issue related to treatment studies and their relevance to clinicians’ engagement in evidence-based prac­ tice regards the quality and quantity o f studies available on a given topic. The quality o f an empirical study, particular­ ly those investigating treatments, largely concerns its in­ ternal validity and its external validity. Study methodolo­ gies that promote internal validity (e.g., randomization o f patients, blinding o f assessors) are what allow researchers to make strong causal statements regarding the manipulat­ ed independent variable (e.g., Treatm ent X ) and a specific dependent variable (e.g., language comprehension). Study methodologies that promote external validity (e.g., ran­ dom selection from a population) are what allow research­ ers to make strong statements regarding the generalization o f findings from their sample to a larger population. N ot all studies are done well (Justice et al., 20 0 8 ) and those that are o f poor quality can lead the clinician engaging in evidence- based practice to make undesirable treatment recommenda­ tions. The quantity o f studies available on a given topic is an additional issue o f relevance to evidence-based practice. The clinician’s access to one study showing a positive effect for a given treatment should not be nearly so influential to his or her decision-making as having access to five studies that show consistently positive treatment effects. Knowledge is created through the accumulation o f evidence and our prac­ tices should change only when there is a preponderance o f compelling high quality evidence. An important structure that has yet to be developed in the field o f speech-language pathology in the United States is explicit guidance regarding how many treatment studies are needed for a given treatment to be considered “empiri­ cally validated.” A t the present, a speech-language pathol­ ogist may consider a specific treatment to be “empirically validated” or scientifically based on the basis o f only a single study o f any design reporting positive effects o f that treat- IN S P E E C H - L A N G U A G E P A T H O L O G Y : S C A L IN G U P O F C O M M U N IC A T IO N D ISO RD ER S, V O L . 55 2 0 0 8 | 9 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) LAURA M. JUSTICE Table 1. E xam ples o f m eta-analyses on clinically relev an t topics in speech-language p athology Topic Citation i T reatm ent of Law, J., G arrett, Z , & N ye, C. child language (2 0 0 5 ). T h e efficacy o f treatm ent for ; disorders children with developm ental speech and langu age delay/disorder: A m eta-analysis. J o u rn a l o f S p e e c h , L a n q u a g e , a n d H e a r in g R e s e a rc h , 4 7, 9 2 4 -9 4 3 . :■ Im pact of C ohen, S. M , D upont, W . D , & voice Gourey, M. S. (2 0 0 6 ). Q uality o f life i disorders on impact of non-neoplastic voice quality of life disorders: A m eta-analysis. A n n a ls o f O to rh in o la ry n g o lo g y , 115, 12 8 - s* 134. : T reatm en t of W hurr, R , Lorch, M ., & N ye, C. aphasia (1 9 9 2 ). A m eta-analysis of studies : carried out betw een 19 4 6 and 1988 concerned with the efficacy of speech and langu age therapy treatm ent for aphasic patients. In te rn a tio n a l J o u rn a l o f L a n g u a g e a n d C o m m u n ic a tio n D is o rd e rs , 27, 1-18. i T reatm ent of R obey, R. (1 9 9 8 ). A m eta-analysis aphasia of clinical outcomes in the treatm ent of aphasia. J o u rn a l o f S p e e c h , L a n g u a g e , a n d H e a rin g R e s e a rc h , 4 1 , 172 -1 8 7 . ! T reatm en t of Boutsen, F , C annito, M . P , Taylor, spasm odic M ., & B ender, B. (2 0 0 2 ). Botox 1 dysphonia treatm ent in adductor spasm odic with Botox dysphonia. J o u rn a l o f S p e e c h , L a n g u a g e , a n d H e a rin g R e s e a rc h , 4 5 , 4 6 9 -4 8 1 . i Treatm ent of R uotsalainen, J. H , S ellm an, J., ! functional Lehto, L., Jauhiainen, M , & i dysphonia Verbeek, J. H. (2 0 0 7 ). Interventions for treating functional dysphonia in adults. C o c h ra n e D a t a b a s e o f S y s te m a tic R e v ie w s , 3 (# C D 0 0 6 3 7 3 ) i T reatm ent of Hopkins, C , Yousaf, U ., & I hoarseness Pedersen , M. (2 0 0 6 ). Acid reflux i secondary to treatm ent for hoarseness. C o c h r a n e acid reflux D a t a b a s e o f S y s te m a tic R e v ie w s , 1 (# C D 0 0 5 0 5 4 ) ment. This is problematic in a number o f ways, the least be­ ing that the authors o f a study may readily argue positive treatment effects even when the study design does not per­ m it strong causal claims or there was a fatal flaw in the de­ sign. O ther fields have set minimal standards regarding the strength o f evidence needed - in terms o f both quantity and quality o f treatment studies - for a practice to be empirically validated (e.g., Lonigan, Elber, & Johnson, 1998). However, the field o f speech-language pathology has yet to develop this important structure which, in my opinion, is absolutely necessary for clinicians to be discerning consumers o f the accumulating empirical literature and to successfully engage in evidence-based practice. Clearinghouses Speech-language pathologists are busy. In an era o f lim ­ ited financial resources, clinicians are constantly being asked to do more for less. As a result, it is unreasonable to expect speech-language pathologists to conduct a thorough high- quality review o f the empirical literature for every clinical issue that they must address. N ot only do clinicians lack the time to engage in such activities, but they may not have ac­ cess to the physical resources to do so (e.g., electronic jour­ nals, databases) and they may not have the skills necessary to conduct what amounts to an informal meta-analysis o f the accumulated research papers available on a given topic. Consequently, an absolutely critical resource necessary for the scaling up o f evidence-based practice is the development o f clearinghouses that allow clinicians to study condensed and useable descriptions o f the accumulated scientific lit­ erature on a specific topic. Currently, there are two types o f clearinghouses that provide interpretations o f the empirical literature: (1) clearinghouses that publish systematic reviews and meta-analyses that are commissioned or volunteered to address specific topics, and (2) clearinghouses that provide links to resources on evidence-based practice, such as lists o f studies on a given topic and links to practice guidelines on specific topics. Examples o f this latter type o f clearinghouse include the American Speech-Language-Hearing Associa­ tion’s Compendium o f E B P Guidelines and Systematic R e­ views (www.asha.org), and The National Guideline Clear­ inghouse (www.guideline.gov), an initiative o f the United States Departm ent o f H ealth and Human Services’ Agency for Healthcare and Quality. O f the two types o f clear­ inghouses, the former is the decidedly more useful to the clinician engaged in evidence-based practice, as it provides access to systematic reviews and meta-analyses that sum­ marize a body o f work for the busy clinician. These reviews and meta-analyses are typically prepared by experts in the field and they must follow specific guidelines regarding how to identify studies on a specific topic, how to analyze these, and how to report findings. Likely the two most well known clearinghouses are that o f the Cochrane Collaboration (www.cochrane.org) and the Campbell Collaboration (www.campbellcollaboration.org). B o th are international non-profit organizations that exist specifically to develop systematic reviews o f the available literature on treatment and assessment in the field o f health and medicine (Cochrane) and social and behavioral sciences (Campbell). N ot only do these organizations provide access to a large database o f reviews on a range o f clinically Rele­ vant topics, but numerous tools are available to support one’s developing knowledge o f how to engage in evidence-based practice and how to conduct critical reviews o f the scientific literature. A more recent addition is the W h a t Works Clear­ inghouse (ies.ed.gov) o f the United States Departm ent o f Education; this clearinghouse both commissions and dis­ seminates systematic reviews o f educationally-relevant in- 10 | DIE S U ID -A FR IK A A N S E TY D S K R IFV IR K O M M U N IK A S !E -A F W Y K IN G S ,V O L . 5 5 ,2 0 0 8 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) http://www.asha.org http://www.guideline.gov http://www.cochrane.org http://www.campbellcollaboration.org E V ID E N C E - B A S E D P R A C T IC E IN S P E E C H - L A N G U A G E P A T H O L O G Y : S C A L IN G U P tm diei m d m k d t y relevant t o fiu m speech-language pathology Topic ‘ T re a tm e n t for child la n g u a g e disorders T re a tm e n t fo r child phon ological disorders T re a tm e n t for p relinguistic c o m m u n icatio n T re a tm e n t o f stuttering T re a tm e n t fo r a p h a s ia T re a tm e n t fo r d e m e n tia Citation T reatm ent for reading difficulties Throneburg, R. N ., C alvert, L. K., Sturm, J. J-, Param bo ukas, A. A., & Paul, P. J- (2 0 0 0 ). A com parison of service delivery models: Effects of curricular vocabulary skills in the school setting. A m e ric a n J o u rn a l o f S p e e c h -L a n g u a g e P a th o lo g y , 9, 10- 20 . Tyler, A. A., Lewis, K. E., Haskill, A., & Tolbert, L. C . (2 0 0 3 ). O utcom es of different speech and language goal attack strategies. J o u rn a l o f S p e e c h , L a n g u a g e a n d H e a rin g R e s e a rc h , 4 6 (5 ), 1 0 7 7 - 1094. Yoder, P. J., & W arren, S. F. (2 0 0 1 ). R elative treatm ent effects of two prelinguistic comm unication interventions on langu age develo pm ent in toddlers with developm ental delays vary by < m aternal characteristics. J o u rn a l o f S p e e c h , L a n g u a g e , a n d H e a rin g R e s e a rc h , 44 (1 ), 2 2 4 -2 3 7 . Riley, G . D ., & Ingham , J. C. (2 0 0 0 ). Acoustic duration changes associated with two types of treatm ent for children w h o stutter. J o u rn a l o f S p e e c h , L a n g u a g e a n d ' H e a rin g R e s e a rc h , 4 3 (4 ), 9 6 5 -9 7 8 . i Elm an, R. J . , & Bernstein-Ellis, E. ; (1 9 9 9 ). T h e efficacy o f group i comm unication treatm ent in adults t with chronic aphasia. J o u rn a l o f ! S p e e c h , L a n g u a g e a n d H e a rin g R e s e a rc h , 4 2 (2 ), 4 1 1 -4 1 9 - C hapm an, S. B., W ein er, M . F., * Rackley, A ., H ynan, L. S ., & Zientz, J. (2 0 0 4 ). Effects of cognitive-com munication stimulation for A lzheim er's disease patients treated W ith D onepezil. J o u rn a l o f S p e e c h , L a n g u a g e a n d H e a rin g R e s e a rc h , 4 7 (5 ), 1 1 4 9 - 1163. Berninger, V . W ., V erm eu le n , K., Abbott, R. D., M cC utchen, D ., Cotton, S., C ude, J., et al. (2 0 0 3 ). C om parison o f three approaches to supplem entary reading instruction for low-achieving second-grade readers. L a n g u a g e , I S p e e c h , a n d H e a rin g S e rv ic e s in S ch o o ls. 3412), 1 0 1 -1 1 6 ._________ terventions on various topics (e.g., Phonological Awareness Training, Shared B o o k Reading) but also gives “ratings o f effectiveness” to specific interventions that include positive effects, potentially positive effects, mixed effects, no dis- cernable effects, and potentially negative effects; addition­ ally, studies included in their reviews are also graded for the quality o f the design (strong, weak). Several other clearinghouses aside from Cochrane, Campbell, and W h a t Works may also offer information o f relevance to speech-language pathology. The California Evi­ dence-Based Clearinghouse for Child Welfare (www.cachil- dwelfareclearinghouse.org) is organized similarly to that o f the W h a t Works Clearinghouse and provides commissioned reviews o f topics related to child welfare. O n the basis o f the available evidence, specific interventions are rated for the strength o f evidence (e.g., well-supported by scientific evi­ dence, lacks adequate research evidence). Although many o f the reviews available are not directly relevant to the speech- language pathologist, some may be informative to clinical practice, such as the reports in the topic areas addressing Youth Transitioning into Adulthood and Parent Training. The Coalition for Evidence-Based Policy offers summaries o f well-conducted randomized controlled studies on a va­ riety o f topics through their Social Programs That W ork clearinghouse (www.evidencebasedprograms.org). Recent reports describe effects associated with the Nurse-Family Partnership (a home visitation program) and the Abecedar­ ian Preschool project (an early intervention program). The C enter for D ata-D riven Reform in Education offers sum­ maries o f scientific reviews in its B est Evidence Encyclope­ dia (www.bestevidence.org). Reviews concerning the use o f technology to teach reading and approaches to promoting literacy in English Language Learners may be o f interest to speech-language pathologists. The Promising Practices N et- { work offers the Programs That W ork Clearinghouse (www. I promisingpractices.net), which offers summaries o f effica- j cious programs relevant to intervention for and education j o f children; programs are organized into categories based S on the apparent strength o f evidence (e.g., proven programs, | promising programs). i Concluding Comments j Evidence-based practice is a process to which speech- j language pathologists may adhere when making decisions ! concerning the assessment or treatment o f communica- i tion disorders. The clinician who engages in evidence-based practices carefully considers and integrates various types o f 1 evidence to arrive at the most effective solution to a specific S clinical question. The types o f evidence examined include, ! at the least: (1) clinical expertise, (2) patient values and per- 1 spectives, and (3) best available scientific evidence (Sackett et al., 1 9 9 6 ,2 0 0 0 ). W h ile the former two types o f evidence 1 are readily available to the clinician, accessing the best avail- 1 able scientific evidence may take a great deal o f work and ] presents one o f the largest challenges the clinician faces who seeks to engage in evidence-based practice. Consequently, \ structures must be put into place that enable the speech-lan- j guage pathologist to readily access and synthesize the rel- ! evant empirical literature and to consider its implications 1 for a given clinical question. These structures are what will j permit the scalability o f evidence-based practice, and in- T H E S O U T H A F R IC A N J O U R N A L O F C O M M U N IC A T IO N D ISO RD ER S, V O L . 55 2 0 0 8 11 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) http://www.evidencebasedprograms.org http://www.bestevidence.org LAURA M . JUSTICE elude, in part, systematic reviews and meta-analyses, treat­ ment studies, and clearinghouses that together provide use- able reports, syntheses, and interpretations o f the scientific literature. W ith o u t these structural supports, it is unlikely that evidence-based practice can be scaled up in a way that has positive impacts on practice. Future efforts regarding the promotion o f evidence-based practice must focus not only on training clinical professionals how to engage successfully in this practice, but also the building o f those structures nec­ essary for the field to successfully transition from relying on craft to one that relies largely on evidence. References Academy of Neurologic Communication Disorders and Sciences (2001/ Evidence based practice guidelines fo r the management o f communication disorders in neurologically impaired individuals. Retrieved June 15, 2008 from http://www.ancds.org/practice. shtml. American Speech-Language-Hearing Association. (2005). E v - idence-Based Practice in Communication Disorders [Position Statement]. Retrieved from http://www.asha.org/policy. Andrews, G , Guitar, B , 8c Howie, P. (1980). Meta-analysis of the effects of stuttering treatment. Journal o f Speech and Hearing Disorders, 4 5 ,287-307. Cook, B. G., 8c Schirmer, B. R. (2006). What is special about special education? Examining the role o f evidence-based practices. Austin: PRO-ED. Cibulka, M. 8c Aslin, K. (2001). How to use evidence based prac­ tice to distinguish between three different patients with low back pain .Journal o f Orthopedic and Sports Physical Therapy, 31, 678-695. Coelho, DeRuyter & Stein (1996). Cognitive-communicative dis­ orders resulting from traumatic brain injury in adults.Journal o f Speech, Language and Hearing Research, 3 9 ,5-17. Cohen, J. (1988). Statisticalpower analysisfor the behavioral sciences (2nd ed.). Hillsdale: Lawrence Earlbaum Associates. Cohen-Kerem, R., Kisilevsky, V , Einarson, T , Kozer, E , Koren, G , 8c Rutka, J. (2004). Intratympanic gentamicin for Meniere’s disease: A meta-analysis. The Laryngoscope, 114, 2085-2091. Evidence-Based Medicine Working Group (1992). Evidence- based medicine: a new approach to teaching the practice of medicine. Journal o f the American Medical Association, 268, 2420-2425. Fey, M , 8c Justice, L. M. (2006). Evidence-based decision-mak­ ing in communication intervention. In R. Paul and P. Cascella (Ed.), Introduction to clinical methods in communication disorders (2nd ed.). Baltimore: Paul Brookes. Field, M. J., 8c Lohr, K. N. (Eds.). (1990^ Clinical practice guide­ lines: directions fo r a new program. Washington: National Acad­ emy Press. Gersten, R , Fuchs, L., Compton, D , Coyne, M., Greenwood, C., 8c Innocenti, M. (2005). Quality indicators for group experi- ' mental and quasi-experimental research in special education. Exceptional Children, 7 1 ,149-164. Goldstein, H. (2002). Communication intervention for children with autism: A review of treatment efficacy. Journal o f Autism and Developmental Disorders, 32, 5,373-396. Herder, C , Howard, C , Nye, C , 8c Vanryckeghem, M. (2006). Effectiveness of behavioral stuttering treatment: A systemic re­ view and meta-analysis. Contemporary Issues in Communication Sciences and Disorders Journal, 3 3 ,61-73. Justice, L. M , Mashburn, A , Pence, K., 8c Wiggins, A. (2008). Ex­ perimental evaluation of a comprehensive language-rich cur­ riculum in at-risk preschools. Journal o f Speech, Language, and Hearing Research, 51, 1-19. Justice, Nye, Schwarz, McGinty 8c Rivera (2008). Methodological quality of intervention research in speech-language pathology: Analysis of 10 years of group-design studies. Evidence-Based Communication Assessment and Intervention, 2, 46-59. Justice, L. M., 8c Snell, M. (2007). Illustration of a three-step proc­ ess for identifying the level and quality of empirical support for manualized treatments. Evidence-Based Communication Assess­ ment and Intervention, 1 ,37-47. Law ,J, Garrett, Z., 8c Nye, C. (2004). The efficacy of treatment for children with developmental speech and language delay/disor­ der: A meta-analysis. Journal o f Speech, Language, and Hearing Research, 47, 924-94. Lonigan, C., Elber, J., 8c Johnson, S. (1998). Empirically support­ ed interventions for children: An overview. Journal o f Clinical Child Psychology, 2 7 , 138-145. McGinty, A. S., 8c Justice, L. M. (2006). Classroom-based versus pullout speech-language intervention: A review of the experi­ mental evidence. E B P Briefs, 1,1 ,1 -2 5 . National Institute on Deafness and Other Communication Disor­ ders (2007). NIDCD Research Grants fo r Translating Basic R e­ search into Clinical Tools fo r Human Health (R01). Retrieved June 10, 2008 from http://grants.nih.gov/grants/guide/pa- files/PAR-08-017.html. Park, N .W , 8c Ingles, J. L. (2001). Effectiveness of attention reha­ bilitation after an acquired brain injury: A meta-analysis. Neu­ ropsychology, 1 5 ,2 ,199-210. Porter-O’Grady T. (2007). Push parameters forward using evi- dence-based approaches. Nursing Management, 3 8 ,6,58-61. Robey, R. (1998). A meta-analysis o f clinical outcomes in the treatment of aphasia. Journal o f Speech, Language, and Hearing Research, 4 1 ,172-187. Sackett, D. L , Rosenberg, W. M , Gray, J. A , Haynes, R. B , 8c ' Richardson, W. S. (1996). Evidence based medicine: what it is and what it isn’t: It’s about integrating individual clinical ex­ pertise and the best external evidence. British Medical Journal, 312, 71-72. Sackett, D., Straus, S., Richardson, W., Rosenberg, W. 8c Haynes, R. (2000). Evidence-Based Medicine: how to practise and teach E B M (2nd ed). London: Churchill Livingstone. Schlosser, R., Koul, R., 8c Costello, J. (2007). Asking well-built questions for evidence-based practice in augmentative and al- ternative communication. Journal o f Communication Disorders, 4 0 ,3,225-238. Spring, B. (2007). Evidence-based practice in clinical psychology: What it is, why it matters; what you need to know. Journal o f Clinical Psychology, 63, 611-631. Woolf, S. H , Grol, R , Hutchinson, A , Eccles, M , 8c GrimshawJ. (1999). Clinical guidelines: Potential benefits, limitations, and harms of clinical guidelines. British Medical Journal, 318, 728- 730. Yaruss, S., &c Pelczarski, K. (2008). Evidence-based practice for school-age stuttering: Balancing existing research with clinical practice. E B P Briefs, 2 , 4 , 1-8. 1 2 | DIE SUID -AFR IKA AN SE TYDSKRIF VIR K O M M U N IK A S IE -A FW Y K IN G S , VOL. 5 5 ,2 0 0 8 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) http://www.ancds.org/practice http://www.asha.org/policy http://grants.nih.gov/grants/guide/pa-