Banter Speech & Language

Sydney speech pathologists helping adults and children speak for themselves.

Lidcombe Program

The Lidcombe Program for stuttering: my 10 favourite therapy activities

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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 articles and resources:

Banter Speech & Language Banter Speech & Language
Banter Speech & Language is an independent firm of speech pathologists for adults and children. We help clients in our local area, including Concord, Rhodes, Strathfield and all other suburbs of Sydney’s Inner West.

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 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).

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

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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:


Lidcombe ProgramWestmead 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” challengesParents 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.

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

Banter Speech & Language Banter Speech & Language
Banter Speech & Language is an independent firm of speech pathologists for adults and children. We help clients in our local area, including Concord, Concord West, North Strathfield, Rhodes, and Strathfield, and all other suburbs of Sydney.

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.

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

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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

Banter Speech & Language Banter Speech & Language
Banter Speech & Language is an independent firm of speech pathologists for adults and children. We help clients in our local area, including Concord, Concord West, North Strathfield, Rhodes, Strathfield and all other suburbs of Sydney’s Inner West.

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).

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

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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 or webcam (e.g. by Skype).

We listened!

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

Why a pack of printable activities?

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

  • “Telehealth” (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 Skype 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. Skype/Webcam) – even over Skype, 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.

Download The Lidcombe Program Stuttering Activities Volume 2 now!

 

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:

Banter Speech & Language Banter Speech & Language
Banter Speech & Language is an independent firm of speech pathologists for adults and children. We help clients in our local area, including Concord, Rhodes, Strathfield and all other suburbs of Sydney’s Inner West.

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 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).

School-age stuttering research update: mixing and matching treatments to get results

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We need better treatments for school-aged children who stutter. Research groups, like the Australian Stuttering Research Centre (ASRC) and The Stuttering Center of Western Pennsylvania are working hard to develop and test new treatments. But front-line speech pathologists and families of school kids who stutter don’t have the luxury of waiting.

Why not wait for the perfect treatment?

Aside from the strong possibility that no perfect treatment will ever be found, there are at least six compelling reasons to treat stuttering for school-aged children as soon as practicable:

  1. Pre-schoolers respond best to current best-practice stuttering treatments. Stuttering gets harder to treat with age (e.g. Bothe, 2004, Ingham & Cordes, 1999, Onslow & Packman, 1999). For children who stutter but miss the pre-school treatment “window”, the next best time to start treatment is immediately: ideally as soon as possible after starting school.
  2. As children start school, stuttering can lead to social and emotional problems (Conture & Guitar, 1993).
  3. School children who stutter are often bullied because of their stuttering. For example, studies have shown that:
  • 59% of 7-15 year olds who stutter were bullied – 38% on most days or every day (Langevin et al., 1998);
  • 11-12 year old kids who stutter were almost three times as likely to be bullied as kids who did not stutter (Blood & Blood, 2007);
  • school children are far more likely to see peers who stutter as victims of bullying than children who do not stutter (Davis et al., 2002); and
  • bullying during the early school years is strongly associated with subsequent anxiety (Gladstone et al., 2006). Social anxiety usually starts during the early teen years, meaning it’s likely to start to develop during school years (Smith et al., 2014; Messenger et al., 2015).
  1. Children who stutter have more negative attitudes to communication than their peers, and those attitudes worsen during the school years (Denil & Brutten, 1991, Vanryckeghem & Brutten, 1997).
  2. Children who stutter are more likely to repeat a grade than children who do not stutter (Boyle et al., 1994).
  3. Stuttering children report a lower quality of life than children who do not stutter (Beilby et al., 2012).

A one-size-fits-all approach doesn’t work

As any parent, carer or teacher knows, school-aged kids are not all the same. Far from it.

One challenge for speech pathologists in practice is that many of the clinical trials of stuttering research are conducted on monolingual children without any other communication, mental health or other issues. While we clinicians read this research avidly, there’s always a worry in the back of our minds that the results of some of these studies may not be as easily replicated with our “real world” clients, especially for clients with multiple, sometimes complex needs.

In my practice, I come across children who stutter and are very verbal, mature, social, and intelligent. I also work with children who stutter and also have other communication issues, such as speech sound issues, language learning impairments, auditory processing disorders, working memory impairments or a combination of these. Some of my clients have a history of other issues, e.g. ADHD or anxiety issues. More than half of my clients speak more than language. Many of my recent referrals have been through more than one previous treatment, such as the Lidcombe Program or the Westmead Program (or both) without success.

Finding the right stuttering treatment for more school-age children and their families requires a good understanding of the research (and its limitations). But it also requires creativity to apply the research and discipline to measure outcomes. We also need to focus on the right outcomes – not just the percentage of syllables stuttered, but the effects of the treatment on the child’s mental health, social participation and quality of life.

New mixed treatment focused on real world outcomes

For some school-aged children who have not responded to the Lidcombe Program or the Westmead Program with previous speech pathologists, I have sometimes needed to experiment with different variables to see if I can make a difference. In consultation with the client and family, I have sometimes mixed and matched strategies from different treatments to find a combination that works for the client (and his or her family).

Although I’ve had some good results, I’ve always been concerned to ensure I stick as far as possible with treatment protocols that have been shown to be effective in peer-reviewed research. That’s why I’m so excited about a new peer-reviewed study on a mixed (or “hybrid”) stuttering treatment.

Cheryl Andrews and her colleagues from the ASRC, have just published the results of their Phase II trial of a syllable-timed speech treatment for school-aged children who stutter. (You can read more about the Phase I trial that preceded this study here.) In summary:

  • 22 school-aged children who stuttered were studied, aged 6-11 years: 16 boys and 6 girls;
  • 3 children withdrew before the end of Stage 1, and 3 (of the remaining 19) did not meet the requirements to graduate into Stage 2;
  • 14 of the children had had previous treatment (6 with more than one course of treatment);
  • 9 of the children had other issues, including language learning impairments, speech sounds issues, ADHD, literacy problems, and obsessive-compulsive disorders;
  • 17 of the children spoke more than one language (although all were proficient in English, and none spoke a syllable-timed language, which was necessary for the trial); and
  • some of the children had very severe stutters (one stuttered almost 1 in 3 syllables) and others had very mild stutters (one child stuttered less than 1 in 100 syllables).

The researchers said they included a mix of children to give the study external validity. They also measured a range of outcomes including stuttering severity, satisfaction with treatment and quality of life. In other words, the researchers specifically designed the treatment for a population of real world school-aged children who stuttered, and measured success by real world outcomes that mattered to the children and their families.

Fantastic stuff!

The two-stage treatment combined:

For the 16 children who completed Stage 1 of the program, it took an average of 10.7 sessions over an average of 21.6 weeks (with a range of 9 to 39 weeks). Outcomes were measured at several points, including 12 months after entry into Stage 2 of the treatment.

Study Results

  • Percentage of syllables stuttered: This fell from an average of 8.4% to 1.9% – a 77% average reduction. But there was a wide range of individual outcomes – 2 children did not respond at all to the treatment. No child stopped stuttering completely, although 5 children stuttered less than 1 in every 100 syllables (i.e. very mildly) 12 months after the end of Stage 1.
  • Children’s own assessment of their stuttering severity: Consistent with the percentage of syllables stuttered, the children reported an average 64.9% reduction in their stuttering severity.
  • Avoidance of eight real world situations: 11/16 children reduced their avoidance in social situations compared to pre-treatment, although social avoidance remained an issue.
  • Children’s satisfaction with their fluency: All the children were more satisfied with their speech fluency, except for one child whose satisfaction levels remained the same.
  • Impact of stuttering on quality of life: On a standardised quality of life assessment, all children reported a statistically significant improvement, except for one.
  • How rhythmic the children’s speech was after the treatment: The children’s speech in normal conversation did not sound more rhythmic after the treatment – in fact it sounded slightly less rhythmic!

Clinical bottom line

This great study is immensely helpful for speech pathologists and families working with school-aged children who stutter:

  • As a Phase II trial, it showed promising results for a hybrid treatment to reduce stuttering severity and increase the quality of life of some school-aged children who stutter. It provides sufficient evidence of a possible treatment effect to warrant a randomised controlled trial of the treatment to accurately measure treatment effects (with reduced risk of bias).
  • It gives speech pathologists practical clinical support (and confidence) to keep working with families to tailor evidence-based treatments to the particular challenges and needs of school-age children who stutter.
  • It reminds us to measure outcomes that matter most to the client.

I’ll be hanging out for the Phase III randomised controlled trial!

Related articles:

Principal source: Andrews, C., O’Brian, S., Onslow, M., Packman A., Menzies, R & Lowe, R. (2016). Phase II trial of a syllable-timed speech treatment for school-age children who stutter. Journal of Fluency Disorders 48, 44-55.

Image: http://tinyurl.com/z9kejl6

Banter Speech & Language Banter Speech & Language
Banter Speech & Language is an independent firm of speech pathologists for adults and children. We help clients in our local area, including Concord, Rhodes, Strathfield and all other suburbs of Sydney’s Inner West.

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 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).

Why does the Lidcombe Program for childhood stuttering work: a case of “words will never hurt me”?

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The Lidcombe Program is an effective stuttering treatment for children under 6 years of age. Lidcombe Program treatment is 7.5 times more likely to reduce stuttering than natural recovery (Onslow et al., 2012).

You can read more about the Lidcombe Program here and here and here.

So why does it work?

A. Reward and punishment

When you cut through the jargon, the idea behind the Lidcombe Program is simple. You reward the behaviour you want (smooth, fluent speech). You punish the behaviour you don’t want (stuttering).  It’s like those classic experiments where you give a rat some food when it behaves (does what you want), and jolt it with electricity when it doesn’t.

If, like me, the word “punish” makes you feel a bit squeamish when it comes to kids who stutter, you’re not alone. When talking about this aspect of the treatment, speech pathologists and researchers use all sorts of euphemisms – e.g. the snappy “verbal contingencies for stuttered speech” – to talk about the things we do to discourage stuttering.

Here’s what I find challenging: We think stuttering is a physical problem caused by a “glitch” in the brain. If we’re right, is it fair to ‘punish’ a child for something he or she can’t control?

The best answer to this question is of course that the Lidcombe Program works. Other answers are that the treatment focuses much more on rewards; and that the ‘punishing’ aspects of the treatment are not, in fact, very punishing.

Let’s look at these arguments in more detail.

B. Sticks and stones

(a) “But words will never hurt me”: the 5 verbal contingencies

The big difference between the Lidcombe Program and those rat experiments is that you reward and punish smooth speech and stuttering with words, rather than snacks and zaps. In response to a child’s speech, you use 5 different kinds of words and phrases to reward smooth talking and to discourage stuttering. In Lidcombe Program jargon, we call those words and phrases “verbal contingencies” because they are:

  • words (i.e. “verbal”); and
  • said in response to what the child does (i.e. the words and phrases parents use are “contingent” on what the child does, i.e. whether they stutter or speak smoothly).

Parents are trained to:

  • reward their child for fluent speech with specific kinds of praise, comments and questions with a positive answer; and
  • ‘punish’ their child for stuttering with no response, with comments on stuttering or requests for correction.

In reality, parents tend to mix and match the contingencies: one study of parents actually doing the treatment identified 21 different types of contingencies used by parents, most of which were the 5 “official” contingencies or combinations of the 5 (Swift et al., 2016).

(b) More rewards

The other big difference from rat experiments is that we focus much more on rewarding the child for fluent speech than on punishment. We do this by setting up activities in a way that makes it easier for the child to speak without stuttering. In this way, we get lots more opportunities to reward the child than to respond negatively to their stuttering. When I was first trained in the Lidcombe Program, we were told to reward the child at least 5-10 times as often as we responded negatively to stuttering, and this is a useful rule of thumb to avoid commenting on stuttering too often.

In practice, I give a lot more praise and other positive feedback for smooth speech than comments on stuttering, primarily because I work hard to set up the session so the child doesn’t stutter much (if at all) during treatment. This is consistent with what most parents do in the real world. One recent study showed 91% of verbal contingencies were for fluent speech, with only 6.8% for stuttering (and 2.7% given in error) (Swift et al., 2016).

C. Is the Lidcombe Program safe?

Yes.

When the idea of reward and punishment behavioural treatments for stuttering was first put forward, some academics thought it would harm children’s psychological development, or strain the family bond between parents and their kids, or hurt language development, or even change their children’s social use of language (e.g. Cook & Rustin, 1997).

Thankfully, none of these things is true. Lots of research shows the treatment is safe (Woods et al., 2002; Bonelli et al., 2000; Latterman et al., 2005).  Many families report that they come to value the daily “smooth talking” time together.

D. Does everyone love the Lidcombe Program?

No.

Lots of families love the Lidcombe Program – especially its results. But it’s hard work, especially when progress is slow, if stuttering fluctuates, or if there are setbacks.

It’s the speech pathologist’s job to help parents to troubleshoot problems and to stay the course despite difficulties (e.g. fatigue, scheduling problems, interference from brothers and sisters). At the outset of treatment, I give parents a road map so they can see the ‘big picture’ and encourage them to speak openly about obstacles so I can help. I also warn parents upfront that:

  • although the idea is simple, in practice, the program can be very difficult for parents to deliver, with some parents reporting feelings of guilt and frustration (e.g. Goodhue et al., 2010);
  • some children don’t like the verbal contingencies (e.g. Onslow et al., 1990);
  • negative reactions to verbal contingencies are fairly common, particularly at the beginning of treatment (Packman, 2007);
  • some children appear to become decreasingly responsive to the verbal contingencies or even irritated by them (Hayhow, 2009);
  • if parents give too many verbal contingencies for fluent speech, they can lose their reinforcing value (Chance, 2006); and
  • when doing the program, some children may feel that they have done something wrong when they stutter (Goodhue et al., 2010). This can be tricky: on the one hand, we have to let the child know that stuttering is not their fault; but, on the other hand we are giving contingencies rewarding fluency and discouraging stuttering.

Probably the most controversial of the punishments (verbal contingencies for stuttering) is the “request for correction”. In simple terms, you tell the child she’s stuttered and ask her to say it again. Face-to-face with a child, it can be the most confronting contingency. Some children do not respond well to it, although many do. Some parents don’t like doing it, although others report that it seems to reduce stuttering.

E. So what are the essential elements of the Lidcombe Program? 

We don’t know!

Because of the Lidcombe Program’s theoretical basis, we have assumed that rewarding fluent speech increased smooth speech; and that punishing stuttering decreased stuttering (e.g. Onslow et al., 2001). In other words, we assume that the verbal contingencies are the “active ingredient” that makes the treatment work. But there are other possible explanations for why the Lidcombe Program works, e.g.:

  • the daily opportunity for the child to practice speaking with no or very little stuttering;
  • the positive relationship between parents, the speech pathologist and the child;
  • engagement of the parent and child in a regular, enjoyable activity, which they complete together;
  • increased, positive attention from parents;
  • increased parent focus on speech, including measuring progress;
  • overall increased language-based interactions between parents and children; and
  • unknown “functional mechanisms” that speed up the process of natural recovery,

(Sonneville-Koedoot et al., 2015; Onslow & Millar, 2012; Packman et al., 2015; Onslow et al., 1990; Onslow et al., 1994; and O’Brian & Onslow, 2011).

F. Is “punishment” essential?

New research makes us less certain about the role of verbal contingencies – especially about the “punishing” contingencies:

  • One study showed that doing the Lidcombe Program without using the requests for self-correction for stuttered speech was just as effective at reducing stuttering by 50% as doing the program with requests for self-correction (Donaghy et al., 2015).
  • Another study showed that giving more verbal contingencies for stuttered speech (i.e. punishments) in the first 4 weeks of treatment actually increases the amount of time necessary for a child to complete stage 1 of the Lidcombe Program treatment. This study also showed that, in practice, parents give their children fewer verbal contingencies during treatment than expected (Swift et al., 2016).

Taken together, these studies suggest that verbal contingencies for stuttering might not be contributing to treatment outcomes in the simple way we have assumed. However, we need a lot more research before we can safely conclude that verbal contingencies for stuttered speech are unnecessary. It’s possible, for example, that despite the apparent short-term disadvantages of giving them, contingencies for stuttered speech may play a role in achieving and maintaining fluency gains over the long-term (e.g. see Harrison et al., 2004). This would be consistent with principles of motor learning.

G. Clinical bottom line

The Lidcombe Program is an effective and safe treatment for young children who stutter. It’s simple in theory, but can be hard to do in practice. Not everyone likes it, although many do.

We’re not entirely sure why the Lidcombe Program works. Theoretically, giving verbal rewards and punishments for fluent and stuttered speech is essential. But the role of verbal rewards and punishments requires more research, especially for verbal contingencies for stuttered speech.

For speech pathologists, it’s essential that we stay on top of important new research like the research cited below. I do this by attending Lidcombe Program Consortium training sessions, regularly checking for updates on the Australian Stuttering Research Centre website, reading clinical trial reports as they are published, and by calling and emailing researchers and clinicians involved in some of the latest research – most of whom are very happy to discuss their research and its clinical implications.

Related articles:

Principal sources:

  1. Donaghy, M., Harrison, E., O’Brian, S., Menzies, R., Onslow, M., Packman, A., & Jones, M. (2015). An investigation of the role of parental request for self-correction of stuttering in the Lidcombe Program. International Journal of Speech-Language Pathology, 17(5), 511-517.
  2. Swift, M.C., Jones, M., O’Brian, S., Onslow, M., Packman, A., & Menzies, R. (2016). Parent verbal contingencies during the Lidcombe Program: Observations and statistical modeling of the treatment process. Journal of Fluency Disorders, 47:13-26.

Image: http://tinyurl.com/zx2g3bh

Banter Speech & Language Banter Speech & Language
Banter Speech & Language is an independent firm of speech pathologists for adults and children. We help clients in our local area, including Concord, Rhodes, Strathfield and all other suburbs of Sydney’s Inner West.

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 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).