Lidcombe Program

The Lidcombe Program for stuttering: my 10 favourite therapy activities

David Kinnane · 6 June 2020 · Leave a Comment

For parents who have been trained in delivering the Lidcombe Program for stuttering to their children, it can be hard to think up specific activity ideas. Parents often ask me for a list of activities they can use during the early days of Stage 1 of the treatment at home, and that’s the main reason I’ve pulled this FREE resource together.

I also wrote this resource to help other speech-language pathologists – including those in rural and remote communities – who don’t see many kids who stutter, and student speech pathologists.

We hope you find it useful. If you have a moment, let us know what you think.

If you’ve already downloaded Volume 1 and need more activities, see our new Volume 2 low-preparation printable activities pack or Lidcombe Program Starter Series for Highly Structured Practice.

Related resources:

Hi there, I’m David Kinnane.

Principal Speech Pathologist, Banter Speech & Language

Our talented team of certified practising speech pathologists provide unhurried, personalised and evidence-based speech pathology care to children and adults in the Inner West of Sydney and beyond, both in our clinic and via telehealth.

My preschooler stutters: should we do the Lidcombe Program or the Westmead Program (or something else)?

David Kinnane · 6 July 2019 ·

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

We’ve written at length about the Lidcombe Program and the Westmead Program for preschoolers who stutter. We’ve included links to many of our previous articles below.

Before looking at the new evidence and its clinical implications, let’s recap some of the main elements of each treatment:

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.

Related articles:

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.

Image: https://tinyurl.com/y4huy49o

Hi there, I’m David Kinnane.

Principal Speech Pathologist, Banter Speech & Language

Stuttering: will my child recover? Factors that predict recovery and why you shouldn’t wait

David Kinnane · 12 November 2017 · Leave a Comment

About 4% to 8% of children stutter at some point during early childhood (Yairi & Ambrose, 2013). Stuttering usually starts without warning between the ages of 2 1/2 and 4 years of age.

Here’s the good news: at least 80% of young children who stutter will recover spontaneously (Reilly et al., 2013).

Now, the bad news:

so far, we have no reliable way of knowing if a given child will be in the lucky majority; and
those who don’t recover, face significant, negative life impacts – from early childhood to old age (e.g. Bricker Katz, Lincoln & McCabe, 1999).

These two points are why the Australian Stuttering Research Centre no longer recommends a “watch and wait” policy when it comes to children who stutter: especially as early intervention with an evidence-based treatment like the Lidcombe Program or the Westmead Program is safe and effective for preschoolers.

Factors that may be relevant to a child’s likelihood of natural recovery

As a speech pathologist who works with children who stutter, I’m very interested in reading research that helps identify whether a client might be at a heightened risk of not recovering naturally.

A number of factors have been suggested to help spot kids at heightened risk:

a history of persistent (i.e. not recovered) stuttering affecting other family members (e.g. Ambrose et al., 1997);
motor speech abilities (e.g. Walsh, Mettel, & Smith, 2015; Ambrose et al., 2015);
being a boy (e.g. Dworzynski et al., 2007);
being diagnosed at a later age (e.g. Yairi & et al., 1996), although this research is a bit messy because boys tend to start stuttering later than girls (Yairi & Ambrose, 1992); and
brain differences* (e.g. Chang et al., 2008).

Is language development a predictor of recovery?

Many speech pathologists are trained to think of children who stutter as a different category of client from children with language disorders or speech sound disorders. But of course a child who stutters is a child – not a therapy category. Stuttering therapy uses language and speech skills, and we can’t do stuttering therapy without talking! (Hall et al., 2007).

As we’ve written before, some children who stutter also have speech sound disorders. But what about the language skills of children who stutter?

Like all children, different kids who stutter turn up to a clinic with all sorts of different levels of language skills. Some seem to talk in paragraphs, displaying an amazing array of different sentence structures and word forms. Others have delayed language skills, perhaps speaking in only two or three word phrases and simple sentences.

So do children who stutter have poorer language skills than children who don’t stutter? The research is all over the place and hard to reconcile:

Some older studies show no difference between the average language skills of children who stutter and children who do not stutter (e.g. Nippold et al., 1991).
Some researchers have found sub-groups of children of stutter with depressed language skills – often not severe enough to warrant a diagnosis of developmental language disorder (e.g. Bloodstein & Bernstein Rattner, 2008).
Other researchers have found the opposite: that very young children who stutter have (on average) equivalent or better language skills than children who do not stutter (e.g. Watts et. al., 2017).

What one (ageing) meta-study of the research tells us is that children who stutter do not generally score below the typically developing range on language assessments. But (as a group), they tend to score significantly lower on vocabulary and syntax tests (e.g. Ntourou et al., 2011).

What does this all have to do with spotting kids at a heightened risk of not recovering from stuttering?

Recent – and very preliminary – research suggests that children with well-developing expressive syntax skills may be more likely to recover than children with poor language development. The researchers found that monitoring the rate of growth in a child’s expressive syntax skills over time using conversational speech samples may be more predictive of natural recovery than measuring absolute gains between initial assessment and subsequent assessments – especially as every child who stutters has different language skills at initial assessment. Interestingly – and surprisingly – they did not find that vocabulary diversity growth was predictive (Leech et al., 2017 – see citation below).

Now, there are a couple of barriers to putting this research into clinical practice. Measuring the rate of growth in expressive syntax skills from multiple conversation samples is very time-consuming and labour intensive. And (as the authors’ note), there were several limitations with the study, including that it was conducted on older kids who had been stuttering for 1-2 years before they started the study. We need much more research before we can use expressive syntax development as a reliable predictor of recovery.

Clinical bottom line

Most children who stutter recover naturally. But around 1 in 5 won’t, and we can’t tell up-front whether a particular child will recover. Boys are less likely than girls to recover naturally; and kids with a family history of prolonged stuttering, kids with delayed motor speech skills, and older kids may be more at risk of not recovering than others.

When assessing children who might be stuttering, speech pathologists should assess fluency, but also speech, oro-motor skills, and language development. Language assessments should include sentence- and discourse-level tasks, including conversation samples. In therapy, speech pathologists should choose activities that support both stutter-free speech and more challenging sentence structures and word forms. (This can be built into evidence-based stuttering therapies for preschoolers, including the Lidcombe and Westmead Programs.)

Long-term stuttering causes all sorts of problems at school and in later life. Stuttering gets harder to treat with age – so don’t watch and wait!

Related articles:

Principal source: Leech, K.A., Bernstein Ratner, N., Brown, B., & Weber, C.M. (2017). Preliminary Evidence that Growth in Productive Language Differentiates Childhood Stuttering Persistence and Recovery. Journal of Speech, Language, and Hearing Research, 60, 3097-3109.

*Specifically, differences in measures of cortical grey matter in the superior temporal gyrus and white matter integrity along the arcuate fasciculus.

Image: http://tinyurl.com/y9eoa7zl

Hi there, I’m David Kinnane.

Principal Speech Pathologist, Banter Speech & Language

Which books should I use in stuttering therapy with my child? Here are our favourite six kinds, with examples

David Kinnane · 26 May 2017 · Leave a Comment

“Help! I need some ideas!” A common – and understandable – request from parents and other carers when you work with children who stutter.

Whether your child is doing the Lidcombe Program, the Westmead Program or a hybrid of the two, books are an inexpensive, portable, and (for most children) enjoyable way to get that daily practice done with a minimum of fuss.

Over the years, lots of parents have asked us for specific book recommendations for practice at home. So we thought we’d share some of our most tried and tested resources: books we use in stuttering therapy in our clinic almost every week. Some we’ve found by accident. Others have been recommended to us by other speech pathologists who work with children who stutter.

1. Flap books

These are books where, on each page or two, you lift a flap to reveal a character or (usually hilarious) event. They’re particularly great when you’re working at the single word or short phrase level.

“Who’s under there?”

“Is it a dog?”

Recommendations:

Spot the Dog books by Eric Hill

Dear Zoo by Rod Campbell

2. Find and name books

These are books depicting busy scenes. In some of them, you have to find items. In others, you simply point and name common objects. These books can be used for all levels of language, from single word, to carrier phrase (e.g. “I can see a…”), through to general conversation (“So many animals live on the farm. I like the cow that’s sleeping in the red barn.”)

Recommendations:

Usborne’s The First Thousand Words

Teenage Mutant Ninja Turtles Look and Find

First 1000 Words by Julie Haydon

(Note: I don’t use “Where’s Wally/Waldo?” books much, because they can frustrate some kids and distract from what matters most – fluency!)

3. Sentence completion books

Some kids love particular books so much that they learn them by heart. Great for practising fluency at all levels!

Recommendations:

Room on the Broom by Julia Donaldson

Where is the Green Sheep? by Mem Fox

We’re going on a Bear Hunt by Michael Rosen

Grandpa and Thomas by Pamela Allen

The Cat in the Hat by Dr Seuss

Berenstain Bears books by Stan and Jan Berenstain

Up in the Tree by Margaret Atwood

4. “Silly” or interesting books that provoke

Some books are guaranteed to get a reaction. They should be used with care – some kids love them, others not so much.

But, for the right child, they’re great for working at sentence, description and story levels. And they can be great for syllable-time speech practice with the Westmead Program.

Recommendations:

This is a Ball by Beck & Matt Stanton

Bamboozled by David Legge

Bad Guys by Aaron Blabey

Treehouse books by Terry Griffiths

5. Wordless books

Great for pre-literate and literate kids alike. Wordless books are fantastic for less structured and structured fluency practice, and syllable-timed speech. Also good for kids who stutter and who also have literacy problems because you don’t get bogged down in “reading the words”.

Recommendations:

Dog on a Digger: The Tricky Incident by Kate Prendergast

Mr Wuffles! by David Wiesner

The Arrival by Shaun Tan

6. Books (and other materials) that play to kids’ interests

I once had a client who loathed books. Wouldn’t touch them with a bargepole. Until I presented my trump card: my deluxe Lego Ninjago Masters of Spinjitzu: The Visual Dictionary. At the end of the session, I had to (almost literally) pry it out of his hands!

Over the years, I’ve had similar reactions from reluctant readers by tracking down books linked to their “favourite things in the world”. From rugby league magazines, football (soccer) trading cards, Superman comics, to Pokemon posters – whatever it takes! And my local library has been a great place to run, e.g. when a client had a particular interest in Megalodons.

More stuttering resource ideas: Check out our Lidcombe Program 10 Favourite Therapy Activities (a free download) and our Lidcombe Program Stuttering Activities Volume 2.

Final tip: as your child’s fluency improves, remember to read with – not at – your child to turn the shared book reading into a conversation. You can read more about shared book reading here.

Related articles:

Hi there, I’m David Kinnane.

Principal Speech Pathologist, Banter Speech & Language

Lidcombe Program stuttering activities: Volume 2 printable activities for face-to-face and telehealth therapy now available

David Kinnane · 12 October 2016 · Leave a Comment

When we published The Lidcombe Program for stuttering: my 10 favourite therapy activities back in 2014, we had no idea how popular it would be. Thousands of people from more than 20 countries have downloaded our free resource. Feedback has been overwhelmingly positive, with many parents and speech pathologists reaching out to thank us for sharing activity ideas.

More help needed

We’ve also had a lot of requests from time-poor parents and speech pathologists for specific materials/activities to help them do the treatment. Recently, we’ve had requests from speech pathologists and parents looking for materials to do the treatment by telehealth (e.g. by Zoom, Coviu or Skype).

We listened!

We’re now thrilled to announce the publication of Volume 2: Printable activities for face-to-face and telehealth delivery of the Lidcombe Program

Why a pack of printable activities?

We wanted to publish this pack of printable activities for four reasons:

“Telehealth” (e.g. Zoom, Coviu, Skype and other webcam-based) delivery of the Lidcombe Program has become more popular as the evidence base has grown (e.g. Bridgman et al., 2014). Although some face-to-face resources (like books) can be adapted easily for telehealth delivery, others can’t. With these activities, both the speech pathologist and the family can access exactly the same resources.
Some children (e.g. very talkative children and children with moderate or severe stuttering) may need more time in Stage 1 of the Lidcombe Program to get and stay fluent. Table-top activities like the ones in this pack can help maintain a child’s “buy in”, attention and interest to enable families to focus most on what matters: their child’s fluency.
Some parents have told us that they have used up all the ideas in Volume 1 and want more activity ideas!
For economic and/or cultural reasons, some children do not have access to toys and other resources at home for use in therapy. We want to make the therapy accessible to everyone. (That’s why speech pathologists who purchase this pack for use in their clinic are licensed to share this resource with an unlimited number of their clients without additional cost per client.)

Activities

This guide includes 10 low-preparation, printable activities for children who are being treated with the Lidcombe Program for stuttering. These activities are for children in the highly structured and semi-structured (“practice”) phases of Stage 1 of the treatment and are designed to be used in consultation/with the guidance of the child’s speech pathologist.

What you get

10 “print and play” fun activities with easy-to-follow directions specifically designed to help you administer 10-15 minutes of therapy per day painlessly;
148 pages of printable materials suitable for both face-to-face therapy and telehealth (e.g. Zoom, Coviu, Skype) – even over teleheawlth, the speech pathologist and client can use the same materials;
552 high quality photographs depicting common objects (nouns), places, action words (verbs), and people;
our 8 Speech Legends including Justice the Ninja, Viv the Pirate, Joss the Robot, and Arden the Warrior Princess;
6 attractive colour game boards, including our Smooth Stones Path, Pirate Hunt, Butterfly Chase, Keys to the Castle, Dinosaur Babies, and Freight Attack;
lists of carrier phrases, description attributes, and conversation starters to help deliver the therapy at the level set by the speech pathologist;
guidance on how to use and adapt the activities for different levels of fluency and language; and
additional reinforcement of the main therapy goal – stutter-free speech – with regular reminders from game characters in many activities to focus on smooth speech.

A companion volume

We designed the pack to include lots of cross-over between this pack and Volume 1. For example, we’ve deliberately used the popular grid-format used in Volume 1 to help parents and speech pathologists adapt the games to help administer the therapy. We also encourage parents and speech pathologists to “mix and match” activities and materials from Volume 1 and 2 to maintain interest.

We hope you find the activities as useful in delivering the Lidcombe Program therapy to children who stutter as we do. You can find our Lidcombe Program Stuttering Activities Volume 2 at our Teachers Pay Teachers store.

If this isn’t for you now, no worries! Volume 1 remains free to download.

You can also read a lot more about the Lidcombe Program and other evidence-based stuttering programs by checking out our free articles: