We get asked this question a lot. Until very recently – we’ve had four main problems answering it properly:
- no published studies comparing the two programs head-to-head*;
- generally lower quality evidence for the Westmead Program (see below);
- most of the high-quality, published studies about both the Lidcombe Program and the Westmead Program have been carried out in specialist university clinics (rather than in community and private practice clinics); and
- most of the kids in the high-quality studies have not had any communication issues other than stuttering, e.g. speech sound disorders or developmental language disorders**. This has sometimes made it hard to apply the research to our “real world” case load.
A. New research
A new study has been published that – to an extent – allows us to answer these questions with more confidence.
B. Lidcombe and Westmead Programs – the basics
Before looking at the new evidence and its clinical implications, let’s recap some of the main elements of each treatment:
|Lidcombe Program||Westmead Program|
|What is it?||A behavioural treatment in which a parent gives particular “verbal contingencies” in response to the child’s stutter-free speech, and, less often, in response to the child’s stuttered speech.||A behavioural treatment in which parents and children are trained to speak using syllable timed speech (STS).|
|What does it involve in terms of clinic visits?||45 minute weekly sessions with the speech pathologist.||Initially, 45 minute weekly sessions, quickly reducing to 30 minute fortnightly sessions once the family have learned the pattern.|
|How is the treatment structured?||Two stages: instatement (when the child learns to be fluent in the clinic and in the real world); and then a year of maintenance to manage relapse risk.||Two stages: instatement (when the child learns to be fluent in the clinic and in the real world); and then a year of maintenance to manage relapse risk.|
|What does it involve in terms of daily home practice?||Initially, 10-15 minutes of dedicated parent-child practice at home every day in dedicated “practice sessions”, slowly morphing into using the contingencies with the child in every day speaking situations (depending on progress).||The parent learns to use STS and then prompts the child to use it in every day speaking situations, 4-6 times a day for 5-10 minutes each time. (There are no dedicated 1:1 daily practice sessions.)|
|How long does it take?||The clinical trials to date suggest a median of 16 clinic visits to complete Stage 1. This number is distorted by drop outs. (See below)||The research to date suggests an average of 12 clinic visits to complete Stage 1. Again, distorted by high drop out rates (see below).|
|Common “real world” challenges||Parents need to find 10-15 minutes for dedicated 1:1 daily practice sessions. (Harder than it sounds, especially when family has more than one child, and/or when both parents are working out of the home.)|
Children need to comply with parent verbal contingencies, including prompts not to stutter and to self-correct stutters when their parents ask them to.
It can be a struggle, initially, to find a way to persuade talkative children to reduce their talking to a level that helps them to stay fluent, especially in the early stages of practice.
Some families report a lack of confidence doing the treatment, or telling the difference between stuttered and stutter-free speech. Some families have feelings of being “lost” in the treatment, overwhelmed or guilty about their child’s progress. (It’s the speech pathologist’s job to help parents through these obstacles and feelings.)
It can sometimes be unclear if some children, including some children with ADHD and/or Autism Spectrum Disorder, or developmental delays, are listening to the contingencies and/or whether they care enough about them to make behavioural changes to the way they speak.
When the child has other communication challenges, e.g. significant developmental language disorders or speech sound disorders, it can be hard to prioritise treatments and there is not a lot of evidence to guide clinicians because most of the published studies exclude children with other communication challenges.
In the real world, lots of families drop out before the treatment is complete. There are probably lots of reasons for this – but the expense of weekly clinic visits can be a big issue for many families.
|Can get repetitive and boring! |
Finding the time to do 4-6 sessions of 5-10 minutes of STS per day in daily activities can be difficult. Some children (and some families) get sick of speaking in the pattern quickly (although many don’t – some kids love using it because they can speak fluently).
In the published studies, more than half of families drop out of the treatment before it finishes. Families often drop out when the symptoms of stuttering appear mild, but sometimes before the child’s fluency stabilises.
|How is progress measured in the clinic?||0-9 in-clinic severity ratings. Speech pathologists have an option to take language samples and to calculate percentage of syllables stuttered.||0-9 in-clinic severity ratings. Speech pathologists have an option to take language samples and to calculate percentage of syllables stuttered.|
|How is progress tracked at home?||Daily severity ratings using the 0-9 scale.||Daily severity ratings using the 0-9 scale.|
|Evidence-base (prior to new study)||Extensive: includes non-randomised clinical trials, randomised clinical trials, randomised clinical experiments, long-term clinical trial follow-ups, and a meta-analysis.||Three preliminary, non-randomised trials, including a case study, an experiment with multiple baselines, and a Phase II clinical trial.|
C. New study: so how do the treatments stack up head-to-head?
Dr Natasha Trajkovski (the lead author in most of the published Westmead Program studies to date) and colleagues have published the results of a three-arm randomised controlled trial of the Lidcombe Program and the Westmead Program.
Participants were 91 pre-school children (61 boys, 30 girls), aged 5 years, 11 months or younger. A number of participants also had other language, speech and developmental disorders: in other words, the population studied was much more like the one I see in the real world in my clinic.
The children were randomised to one of three different groups:
- Lidcombe Program (33 children);
- Westmead Program (28 children); and
- a slightly different version of the Westmead Program, including Lidcombe-style verbal contingencies, and contingencies for STS, which was similar in many respects to the school-aged hybrid treatment we write about here (30 children).
(Given the most effective “window” for treating stuttering is during pre-school years, and the social, mental health, and other costs of stuttering, it would have been unethical not to treat some children or to give one group a placebo.)
Interestingly, the treatments were delivered across four sites in Sydney and Melbourne, Australia: two university research clinics, and two community clinics. The inclusion of community clinic-based speech pathologists (in addition to research clinicians) makes the study conditions more like the “real world”.
Each participant’s stuttering severity was independently assessed at nine months after they had been randomised to treatment groups, and stuttering was measured by percentage of syllables stuttered. The study also looked at how many clinic visits it took for the children to complete Stage 1 of each treatment.
D. Key findings
(a) Drop outs were very significant:
- 27.3% of the Lidcombe Program families dropped out;
- 42.9% of the Westmead Program families dropped out; and
- 43.3% of the Hybrid treatment families dropped out.
The research team suggested three factors that may have contributed to the high drop outs rate:
- around one-third of the kids were treated in community clinics: families who sign up to university clinic-based research may be more likely to stick with it;
- no exclusion criteria: some of the kids had other speech, language and developmental challenges and these children may not have responded as quickly as children in other studies who stuttered but had no other issues; and
- 13 of the kids in the trial were younger than 3 years of age. Toddlers tend to be less compliant than older kids!
(b) At 9 months post-randomisation, there were no statistically significant differences in stuttering outcomes for those kids who didn’t drop out:
- 1.35% syllables stuttered for children treated with the Lidcombe Program;
- 2.02% syllables stuttered for children treated with the Westmead Program; and
- 1.99% syllables stuttered for children treated with the Hybrid Treatment.
(c) It took much longer on average for children treated with the Lidcombe Program to complete Stage 1 of the treatment. The median number of clinic visits required for Stage 1 was:
- 30 (range 7-47) for the Lidcombe Program;
- 18 (range 9-28) for the Westmead Program; and
- 16 (range 4-34) for the Hybrid Treatment.
However, this ignores the much higher rate of drop outs for the Westmead Program.
E. Our key clinical takeaways
- Compared to previous studies carried out in University clinics with children who stutter but have no other issues, this study is much more applicable to our real world case load. Many of the children we see who stutter also have speech and/or language issues and some of the kids we see have other developmental issues as well.
- The new study gives us more confidence in continuing to offer families the option of Lidcombe, Westmead and Hybrid treatments. It also allows us to give families more informed choices when it comes to tailoring treatments to the needs of each child and family.
- The new study allows us to level with families about how hard it is to stick with a treatment right from the start, and to work together to make treatment more relevant and engaging for clients (and their families).
- We can now give families some better information about how many clinic visits to expect for each treatment – a very important consideration when parents are accessing private services.
- For very talkative kids, kids with attention and/or other behavioural issues, and really busy families who signal during assessment that they will struggle to find time to do the Lidcombe Program, this study gives us more confidence to recommend the Westmead Program with contingencies for stutter free speech as a first option (rather than first trialling and struggling with the Lidcombe Program).
- For kids with significant language disorders as well as stuttering, the new study does not suggest we need to change our recent clinical practice of combining shared reading, sentence-level expressive language and verbal reasoning tasks with syllable timed speech practice, and Lidcombe-style contingencies for smooth talking (i.e. a structured hybrid approach). We have found that varying expressive language tasks in the clinic with syllable timed speech increases compliance, and can make home practice easier to complete for busy families – especially verbal reasoning tasks that lead naturally to everyday conversations, e.g. in the car. We adopted this practice partly in response to evidence suggesting that the rate of a child’s language development may be a predictor of stuttering recovery.
- We welcome efforts by the Australian Stuttering Research Centre (ASRC) and others to support families of preschoolers who stutter by addressing real world obstacles to completing treatment. For example, we are very excited about the ASRC’s current project to develop an internet version of the Westmead Program.
- The Lidcombe Program for children who stutter
- The Westmead Program for children who stutter
- Stuttering: will my child recover? Factors that predict recovery and why you shouldn’t wait
- My child stutters. Is it because he’s shy? sensitive? hyper?
- Parent dilemma: What to do if your child stutters and has speech sound problems – research update
- Stuttering treatments: what works for whom? An evidence update
- My school-aged child stutters. What should I do?
- School-age stuttering research update: mixing and matching treatments to get results
- Why does the Lidcombe Program for stuttering work: a case of “words will never hurt me”?
- The Lidcombe Program for stuttering: my 10 favourite therapy activities
- Lidcombe Program Stuttering Activities, Volume 2 (low-prep printable activities for face-to-face and Skype therapy)
- Child developmental language disorders
- Child speech sound disorders
For more information about the Lidcombe and Westmead Programs, visit the Australian Stuttering Research Centre website.
Principal source: Trajkovski, N., O’Brian, S., Onslow, M., Packman, A., Lowe, R., Menzies, R., Jones, M., & Reilly, S. (2019). A three-arm randomised controlled trial of the Lidcombe Program and Westmead Program early stuttering interventions. Journal of Fluency Disorders, 61 (September). See: https://doi.org/10.1016/j.jfludis.2019.105708
* For completeness, note there is a published randomised trial comparing the Lidcombe Program and another program called the Rotterdam Evaluations Study of Stuttering Therapy (RESTART), which also reported no statistically significant difference in outcomes between the treatments (De Sonneville-Koedoot et al., 2015).
** Dr Kate Bridgman, a leading stuttering researcher, pointed out to me via Twitter on 9 July 2019 that some of the more recent Lidcombe Program randomised-controlled trials also did not exclude children who stuttered and also had speech or language issues (e.g. Bridgman et al., 2016 (web-cams), and Arnott et al., 2014 (group therapy)). Dr Bridgman also pointed out that co-morbidity wasn’t a predictor of Lidcombe Program treatment effects in those studies, which is both interesting and counter-intuitive. I’d like to thank Dr Bridgman for taking the time to read and comment on an earlier version of this article.
Banter Speech & Language is owned and managed by David Kinnane, a Hanen- and LSVT LOUD-certified speech-language pathologist with post-graduate training in the PreLit early literacy preparation program by MultiLit, the Spalding Method for literacy, the Lidcombe and Camperdown Programs for stuttering, and Voicecraft for voice disorders. David is also a Certified PESL Instructor for accent modification.
David holds a Master of Speech Language Pathology from the University of Sydney, where he was a Dean’s Scholar. David is a Practising Member of Speech Pathology Australia and a Certified Practising Speech Pathologist (CPSP). David is a part-time Associate Lecturer at the University of Technology Sydney’s Graduate School of Health. David sits on Speech Pathology Australia’s Ethics Board and Professional Standards Advisory Committee.