The Westmead Program


It is important with a treatment that uses a novel speech pattern to be sure that speech is not in any way unusual sounding. So we assembled random post-treatment recordings, 15 seconds in duration, and had non-clinicians listen to them. We instructed them to write down words or phrases that described the samples. None of the words they wrote suggested there was anything unusual sounding about the children’s speech.


Advantages and disadvantages


Advantages


From the Phase II trial results, the WP appears to require minimal clinic contact in order to achieve what we generally accept as clinically satisfactory stuttering control. Not only were clinic visits quite short in duration, with only half an hour needed to complete each scheduled appointment, but clinic visits were also spaced fortnightly for most of Stage 1.


The treatment is also suitable for very young children. With the LP at least, intervention at this age is not advisable because responsiveness appears to depend to some extent on the cognitive development of the child. This is inferred by recovery plot analyses showing treatment to take longer when onset-to-treatment time is shorter (Kingston et al., 2003). However, given evidence that children as young as 3 years may experience negative consequences as a result of their stuttering (Ezrati-Vinacour et al., 2001; Langevin et al., 2009), the need for suitable interventions for that age is pressing.


It is also the case that the WP protocol is straightforward. Participants are only required to practise STS for around 1 cumulative hour per day and have their daily severity scores recorded by their parents. It is also the case that verbal contingencies, particularly those for stuttered speech, raise safety issues. Without the need for verbal contingencies, such fundamental questions of safety may be avoided altogether. It may be the case, however, that the treatment has optimal effects when verbal contingencies are incorporated into it (see Section Conclusions and future directions).


Finally, and perhaps most significantly, given the inherent simplicity of the treatment, it may be possible for the WP to be safely modified and delivered with more cost efficient models, hence increasing health care efficiency and decreasing treatment costs. Those treatment models could include group treatment and stand-alone Internet treatment.


Disadvantages


The Phase II trial has demonstrated that the WP, in its current form, needs some revision. Even though the speech outcomes are positive, a significant rate of withdrawal was associated with the preliminary version of the programme. Although dropouts are common for this type of research, they are nonetheless concerning. Most families ceased treatment because of some extenuating family circumstance. In reality though, many of these families would have continued with treatment if the speech gains made were worth the effort required to continue treatment despite their difficult circumstances. This was not the case, as all nine children who withdrew from treatment had reached a plateau in severity, just above programme criteria, which prevented them from progressing to Stage 2.


Conclusions and future directions


There is a need for an efficacious and simple treatment that can be used with very young stuttering children. Clinical results so far are encouraging and we have begun a randomised controlled trial comparing the WP to the LP. When that trial is complete we will know whether we have access to such an efficacious and simple treatment, and whether we attain further efficiency improvements with group and Internet presentations of it.


Given that most children dropped out of our Phase II trial at the point when low-level stuttering severity plateaued slightly above target criteria, we speculated that further speech gains may be achieved through the application of verbal contingencies for stuttered and stutter-free speech. To conduct this hybrid version of the programme, parents were required to carry out a standard ‘robot talking’ practise session for 5–10 minutes and then immediately switch a to ‘smooth talking’ practice session for another 5–10 minutes. During ‘smooth talking’ practice, the child reverts to customary speech and is given feedback about speech performance, in the same way as with the LP. The advantage of conducting a ‘robot talking’ session immediately beforehand is that fluency can be carried over and parents do not have to manipulate language output to maintain the correct praise to correction ratio. Once verbal contingencies are mastered during structured practise, parents are then taught to add them to unstructured conversation.


By integrating verbal contingencies into the WP, we hope that children may become better equipped to reduce their stuttering past the point at which STS use is efficient. In fact, it is reasonable to foresee that the addition of verbal contingencies to the WP may serve as a valuable second step in a schedule of stepped care2 for children who may otherwise withdraw from treatment for lack of progress or for parents who burn out. We have now completed testing this new WP protocol and have begun a three-arm randomised trial to compare the WP, the LP and the hybrid treatment.


Discussion


Sheena Reilly
We were interested in the dropout rate and the reasons the parents gave for withdrawing from the study and we wondered if that said something about the acceptability of the programme for the parents. Perhaps their kids were just better enough and they did not need to do any more treatment.
Natasha Trajkovski
Most kids did drop out at a very low severity, even though it was in fact above programme criteria. So, I can understand that parents would be satisfied with that outcome and would not want to keep on going, because it is quite an intensive treatment to conduct at home. For them, it was a case of near enough was good enough.
Joseph Attanasio
We also had a question about dropouts. It was quite a large percentage, and possibly the remaining children did in fact remain because they were naturally recovering. In other words, the dropouts might have been the children who did not respond at all well and were not naturally recovering, and the ones you retained were retained for the very reason they were naturally recovering.
Natasha Trajkovski
Of course, natural recovery is always an issue with clinical trials of early stuttering treatments. That is why we did a multiple baseline study: to be sure, at least with those three kids, that it was the treatment that caused the improvements.
Sheena Reilly
We have a question about how the parent and/or the family are involved. The parent comes to each clinic visit and then models STS. Is that all they do? Do they give feedback to the children about their STS?
Natasha Trajkovski
The parents come into the clinic and I sit down with them and ask them to show me what they are doing at home. Then they model ‘robot talking’ to the child and just by hearing the model, the child will usually slip into robot talking. If the child doesn’t slip into robot talking, the parent can simply ask the child to use the pattern. But we don’t like to encourage that because it can tend to be punitive if overused. A better idea is for the parent to start off with closed questioning, which elicits shorter sentences, and then the child is more likely to maintain robot talking.
Sheena Reilly
Does the parent give praise for using robot talking?
Natasha Trajkovski
Yes, the parent says something like ‘good robot talking’ when they hear robot talking. If they don’t hear robot talking, they don’t say anything. If the child stutters, they don’t say anything.
Ann Packman
Could you talk a little bit about LP versus WP, particularly in relation to the age of the child? We understand that they are doing quite different clinical things, but you also talked about future combination of LP features into the WP. The group wondered about the ages for which the two treatments might be suitable, and the age that would most benefit from the hybrid treatment.
Natasha Trajkovski
The youngest child that I have treated with the WP was 36 months. With the LP, treatment at that young age is generally thought not advisable because the treatment depends on some level of cognitive development. The WP is so simple that cognitive maturity isn’t an issue. Regarding the hybrid treatment, we have no idea at all as yet when or under what circumstances that treatment might be more suitable.
Joseph Attanasio
Our thinking was that perhaps what you’re doing is helping the child through some difficulty with dealing with the demands of processing variable linguistic stress that might trigger stuttering as described by the Vmodel (Packman et al., 1996).
Natasha Trajkovski
Yes, I agree. The Vmodel and its potential role with early stuttering treatment was discussed by Packman et al. (2000).
Ann Packman
Some of our group were surprised at how natural the children sounded.3 How long does it take in your clinical experience to go from the ‘choppy robot’ talking to when they first start to sound quite natural?
Natasha Trajkovski
Children only use robot talking during the treatment time itself. Once treatment concludes, children will revert back to customary, natural-sounding speech immediately and spontaneously.
Ann Packman
Returning to the dropout rate, it appears related to meeting the criteria for Stage 1 so that children can progress to Stage 2. Would that be right?
Natasha Trajkovski
Yes, almost but not quite reaching the criteria.
Ann Packman
So our question was, do you think the criteria are too strict? Are you asking too much of the children?
Natasha Trajkovski
I don’t think so. We are asking the same as the LP, which for our purposes are a gold standard for control of early stuttering. The only way we can compare it to the LP, either indirectly with clinical benchmarks or directly in clinical trials, is to use the same criteria.
Ann Packman
But do you think given the dropout rate that that is asking too much? Is it a treatment component that could be manipulated? Could you reduce or make the treatment less intensive for children that are not progressing straight to criteria in the hope of reducing the dropout rate?
Natasha Trajkovski
That strikes me as counter-intuitive in terms of treatment efficacy. If anything, I would do more intensive treatment to get them to Stage 2. I don’t think reducing treatment intensity will solve the dropout problem. Perhaps a stepped care approach will solve the dropout problem, when children fail to quickly attain Stage 2 criteria with the WP the hybrid programme is next.
Joseph Attanasio
On that topic, praising robot talking is a verbal contingency. Would the other contingency then be a correction of not using the robot speech?
Natasha Trajkovski
No, the same verbal contingencies that are used in the LP would be used in the hybrid version.
Joseph Attanasio
Would that not confound the effects of STS? Those contingencies have been shown to be quite potent in laboratory studies.
Natasha Trajkovski
And that’s why we are including them.
Joseph Attanasio
That would complicate the treatment.
Natasha Trajkovski
Yes, and that is why we would introduce them as the second step in a stepped care sequence.
Sheena Reilly
When would you introduce the contingencies for stuttered and stutter-free speech? What will be your criteria for doing that?
Natasha Trajkovski
We have set a criterion that if severity ratings do not fall for 8 consecutive weeks, contingencies are introduced. When introducing contingencies, we keep them separate from the ‘robot talking’ practice. So, we have parents do ‘robot talking’ practice first as usual for 5–10 minutes, and then we get them to immediately switch to the LP verbal contingencies. That way, we plan to maximise carry over from WP treatment benefits to LP treatment benefits.
Ann Packman
The practise requirements of four to six times a day for 5–10 minutes. We were wondering if you could tell us why you chose those particular times.
Natasha Trajkovski
For two reasons. First, preschoolers just can’t concentrate for much longer than 5–10 minutes at a time. Second, from a theoretical perspective, it makes sense that more bursts of STS practice would be better than fewer.
Joseph Attanasio
The image of a robot is strong and powerful. Is it necessary or helpful?
Natasha Trajkovski
I have never thought about that. It is of course arbitrary how you refer to the speech pattern. I guess we just fell into the habit of having parents use the ‘robot talking’ term. One mother I know of calls it ‘syllable talking’ and that did not seem to make a difference.
Sheena Reilly
What do parents think of this robot talking?
Mother4
I found the treatment sort of really easy to get a handle on … and also really easy for HM to do … this robot talking … was really sort of simple and straightforward … we would just have to practise speaking in a robot-like voice together for several minutes and that’s all that was involved … He loved it. He especially liked coming here and he actually quite enjoyed the idea of speaking like a robot.
Natasha Trajkovski
To finish up, I would say that parents do generally like the treatment. They find it easy to learn, but the one thing that parents can have difficulty with is scheduling so many practice sessions. We have next to solve the problem of when that causes non-compliance.


References


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1 A prospective attempt to determine the efficacy of an entire treatment based on at least 3 months follow-up observations of speech beyond the clinic.


2 The Stepped Care model of health care delivery contains two fundamentals (Bower and Gilbody, 2005). It provides the simplest and most cost efficient method of health care that is efficacious. It is self-correcting so that patients progressively escalate to more resource intensive, and less cost efficient, health care models if they are shown to need it. It is suitable for disorders where simple, cost efficient interventions can be used for a significant proportion of those affected, such as brief counselling for weight control or management of substance abuse.


3 Dr Trajkovski showed the group some pre-treatment and post-treatment videos of children during the Westmead clinical trials.


4 Dr Trajkovski then played a video recorded interview with a parent whose child had been successfully treated with the WP. An excerpt of what she said is reproduced here.


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Mar 21, 2017 | Posted by in NEUROLOGY | Comments Off on The Westmead Program

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