Lidcombe Program with School-Age Children

Parents in both Koushik et al. (2009) and Lincoln et al. (1996) reported being satisfied with their children’s post-treatment speech. Koushik et al., interviewed parents of ten of the children about their satisfaction with the LP. Using the 10-point severity scale, seven parents assigned a score of 1 or 2 to their child’s speech at follow-up, indicating no or extremely mild stuttering. Three parents assigned scores of severity 3. Eight parents reported that their child’s stuttering had not worsened since the last clinic visit and two reported a slight increase. Eight parents said they continued to provide occasional verbal contingencies for both stutter-free and stuttered speech. Although all parents enjoyed participating in the LP, six also said that they found it difficult to find time to conduct treatment during structured conversations because of busy home schedules.

It is somewhat difficult to compare the results of Koushik et al. (2009) to that of Lincoln et al. (1996), which was based upon an earlier version of the LP with this age group. While the possibility of a large effect size was reported for both studies, more replication is certainly needed. Koushik et al.’s study may contain positive bias in participant selection because of its retrospective nature. Another limitation is the comparison of in-clinic recordings in the pre-treatment assessment with telephone recordings at the post-treatment follow-up. Although seven children did not achieve the LP criteria at the time for preschool children of %SS less than 1.0 at follow-up, reductions in stuttering were significant for the majority.

The results of a recent case study of an Iranian school-age boy who received the LP (Bakhtiar and Packman 2009) were consistent with the two studies reviewed previously. %SS during the first clinic visit were presented graphically with the boy’s clinic chart, and were around 12 at the first clinic visit. Subsequent improvements began during subsequent, consecutive clinic visits, with reductions to 10, 8 and 5 %SS. At the conclusion of Stage 1, two independent observers measured his stuttering rate to be below 1.0 %SS during recorded conversations beyond the clinic.

In spite of the limitations of these preliminary studies, these findings pertain to an age group less likely than a preschool-age group to experience natural recovery (Yairi and Ambrose, 2005) that eliminates a source of bias.

Advantages and disadvantages

Given that stuttering becomes less tractable after the preschool years, it is clear that an efficacious stuttering treatment for school-age children is of great importance. Verbal response contingent procedures such as the LP are not complicated by programmed instruction, the use of reduced speaking rate or a novel speech pattern. The spontaneous increase of speech rate post-treatment found by Koushik et al. (2009) verifies that claim, and implies that a simple treatment for school-age children is feasible.

The findings of preliminary studies with school-age children justify the need for further clinical trials to establish treatment effects of the LP for this age group. It has been shown that procedurally, a simple treatment like the LP is viable for school-age children and that parents report enjoyment in administering the treatment. In all but one of the 12 children studied, it required no modification to the manualised procedures for school-age children and treatment time to Stage 2 was not longer than that reported for preschool-age children. These results substantiate the Lincoln et al.’s (1996) findings of an earlier version of the LP with this age group and support continued exploration of the LP with young school-age children in subsequent clinical trials.

Although four of the 11 participants maintained an average %SS below 1% at follow-up, seven others did not achieve this criterion, suggesting that there is more variability in Stage 2 outcomes for the school-age population compared to preschool children (Jones et al., 2005). This stuttering severity is comparable with the findings obtained for school-age children from Lincoln et al. (1996) study. The findings of the Lincoln et al. (1996) and Koushik et al. (2009) studies combined suggest that the LP with school-age children may not produce stuttering reductions that are as low as those seen in preschool-age children. This raises questions about what factors might contribute to this poorer outcome in the school-age population. There may be a need to adjust the criteria for entering Stage 2 for this age group, to reflect the potential inability of some school-age children with chronic persistent stuttering to reach the criteria of no stuttering. Since stuttering that persists becomes more resistant to treatment and more complex in nature, some school-age children may be unable to meet the criteria established for the preschool-age group.

While the results of Koushik et al. (2009) are encouraging, the study was preliminary and retrospective, and therefore, likely to contain positive bias associated with behaviours sought by the researchers, by self-selection of speech sampling situations. One limitation of the study is that the pre-treatment and post-treatment measures were not comparable due to the retrospective nature of the study. Additionally, non-speech data would enhance future studies as other variables related to stress and anxiety may affect stuttering in this age group.

One of the encouraging findings for the children in the Koushik et al. (2009) and Lincoln et al. (1996) studies is the number of treatment sessions required. The treatment time of a median eight clinic visits was shorter than those required for preschool-age children, which is around 11 clinic visits to Stage 2. Some explanations for this includes enhanced cognitive function in older children. This may lead to increased capacity for self-monitoring/self-correction, which is not an expectation for the preschool-age children, and may account for a faster treatment time.

Additionally, the ability of the child to participate more actively in the clinical process, through activities that include self-monitoring or self-rating of severity, may have accounted for treatment gains noted even though the children were away from their parents for large parts of the day.

If future studies find this to be an efficacious treatment it would be a welcome addition to the repertoire of the school-age clinician. Benefits of this programme in a school setting would include the short treatment time, and the lack of attention to a novel speaking condition.

Conclusions and future directions

It is worth pursuing the LP with school-age children. Hopefully further studies will continue to provide important information about the characteristics of treatments that are effective and efficacious for this age group. Conducting a prospective replication with a second school-age group would be a positive initial step. This could be followed by a Phase II clinical trial that would serve as a follow-up to the Lincoln et al. (1996) study.

Since persistent stuttering is often characterised by changes in attitudes that may influence treatment outcome, it would be worthwhile evaluating those non-speech improvements that may occur as a result of this treatment. Future studies could include evaluation of attitudes and social anxiety.

It is interesting to speculate about the predictors of best child fit to this approach, and if individual differences such as other speech and language concerns, attention deficit or other co-morbid factors affect treatment outcome. Future research might establish whether such variables are associated with improved clinical compliance and involvement of both the child and parent in a positive way.

More information regarding the use of the LP with school-age children in effectiveness of generalising fluency from within- to beyond-clinic settings is needed. Perhaps a part of that information will be whether children of this age are reliable in collecting their own stuttering severity ratings during everyday life, particularly at school.

Discussion

Ann Packman
This is a question from the sceptics in our group. Koushik et al. (2009) was not a prospective study. Might there have been other children who dropped out or for whom it wasn’t successful? Were the children in that study taken from the waiting list in consecutive order?
Rosalee Shenker
It was a respective study of long-term outcomes of 12 children taken in consecutive waiting list order, and there were no dropouts.
Joseph Attanasio
How does you definition of school age as 7–12 years correspond with the Canadian school system?
Rosalee Shenker
School age for us is defined by the period, in Canada, Grade 1 to Grade 6 before secondary education starts so that would be approximately from 7 to 12 years.
Joseph Attanasio
And is there any differential responsiveness to the treatment during that period?
Rosalee Shenker
I find that the best age within that range for LP treatment is 7–9 years, but that is just my opinion without any research to back it up. I would say that the window closes around 11 years onwards, were we find at the Montreal Fluency Centre that there are better programmes to use, as children get closer to adolescence.
Sheena Reilly
We were intrigued about whether the children were formally requested to self-monitor as part of the programme and if so was that home, school or generally?
Rosalee Shenker
No, not in the Koushik et al. (2009) study. But when we looked at the results for that group of children we made some changes to the way we provide the treatment. Now our procedure is that children of that age, who receive the LP, as well as their parents, collect their own severity scores outside the clinic and bring them each week. We find that useful because, although there is general consistency between parent and child severity scores, often there would be one day where the scores would be different. The child would often experience a lot more stuttering that the parent would record. Parents would often say something like ‘gosh, I didn’t hear you stuttering so much that day, what happened, why did you give yourself that score?’ and the child would say something like ‘because I had to do a presentation in front of the class and I bombed and it was really horrible’. And the parent inevitably would say something like ‘I am so glad I know that, next time I can help you with that’. Clinically, that seems to work really well.
Sheena Reilly
At what age do you think you could start that self-monitoring and self-assessment with children?
Rosalee Shenker
I think safely I could say 7 years, perhaps even a bit younger depending on the cognitive ability of the child.
Ann Packman
We were wondering whether any of the children had previously had the LP treatment and whether you think that might be a help or a hindrance if they had, and especially if they might have failed before.
Rosalee Shenker
None of them had any prior LP treatment. But I don’t recall whether any of them had any other previous treatment.3
Joseph Attanasio
Could you tell us if you have identified any characteristics of the children that make them particularly good candidates for the LP at this age or not good candidates?
Rosalee Shenker
One thing that seems to make them good candidates is that this is the treatment that they want to do. Not when parents want the treatment and the children were unsure, but when children state their compliance. For me, that really stands out as being one important characteristic of this age group that is related to the treatment success. Also, the development of spontaneous self-monitoring.
Sheena Reilly
Do you know anything about the children’s stuttering at school?
Rosalee Shenker
Not from the Koushik et al. (2009) study. But clinically, the children’s severity scores that I mentioned just then, that are currently part of our clinical routine, give us that information. I find such child measures are critical because of the variability of stuttering across childhood situations.
Ann Packman
We were also interested to know if, when children 7–9 years become markedly fluent after LP treatment, they still have some lingering negative speech attitudes and situation avoidance. Also, if they had been teased and bullied, did that just stop with the arrival of stuttering reduction?
Rosalee Shenker
That is something that we didn’t investigate. Of course it would have been better to but it was a retrospective study and we did not have pre-treatment measures of such things. For future studies I do think these measures need to be built in. Obviously it is most important to evaluate with this age group. I must say though that the issue never came up in the clinic with the children and very often when there is an issue the children will tell us, then we respond to it.
Joseph Attanasio
With preschool children treated with the LP, two studies indicated that the treatment does not have a frank effect on language development (Bonelli et al., 2000; Lattermann et al., 2005). In other words, the children were not sacrificing language for fluency. In the older age group where the children may be more sensitive to what they are doing, is there any sense that they might be sacrificing not language development but length and complexity of utterance for fluency? In other words, do you think the kids are shortening and simplifying their utterances to be more fluent?
Rosalee Shenker
I don’t have any idea about that but of course we have the post-treatment samples and we could get some information from those. I do have data on a group of school-age children that we followed up 4–7 years after the LP and we analysed their conversation speech samples and their development was consistent with their age (Shenker and Roberts, 2006).4
Sheena Reilly
Could you talk a little bit more about the follow-up periods, which I think had quite a range, from 9 to 187 weeks with an average of 79 weeks. We were intrigued as to whether there could be a relationship between the time at which you followed up and the outcome?
Rosalee Shenker
We did that analysis and in the paper reported that there was no relation between duration of follow-up and outcome in terms of stuttering severity.
Ann Packman
You mentioned that one child received some adjunct speech restructuring component. What would be the criteria for introducing that? How long would you wait? The Koushik et al. (2009) paper reported such a strategy for only one child of the 12. Would you anticipate that clinicians would encounter more children than that needing such a strategy?
Rosalee Shenker
The reason this child received the speech prolongation addition was that the parent requested it after becoming a little unmotivated and non-compliant with the LP. At the Montreal Fluency Centre we have a chart review of every child who is receiving the LP, regardless of age, at about 5 weeks after the treatment starts. If we are not getting a treatment effect then we do some troubleshooting to try and understand why. For preschool children that almost invariably fixes the problem. For school-age children, if that does not fix the problem, we do another chart review at about 11 or 12 weeks and if the child is still not making progress with the standard LP, then we will consider changing the nature of the therapy. This is a new policy for us.
Joseph Attanasio
You said that treatment time was shorter for these school-age children than preschoolers who typically receive LP treatment. Apart from rate of progress, are there any other differences in treatment responsiveness?
Rosalee Shenker
What comes to mind is that I would say with the older children they more quickly get down to a severity rating of around 3–4 and we will often see progress stalled at that point. I don’t know why, but that is often the time when we have to do a chart review to find out what is causing it. Sometimes the child just becomes unmotivated by the verbal contingencies and we have to explore a change in the verbal contingencies. Sometimes the parent is not using the verbal contingencies much because the child is stuttering less. Sometimes we can fix this with a tangible reward system. Often we can fix it by simply increasing the number of verbal contingencies that the child receives.
Sheena Reilly
You highlighted that one of the problems with the Koushik et al. (2009) data was the different methods for collecting the pre-treatment and post-treatment measures. Would you design the study differently if you were doing it again prospectively? Could you comment on whether you think this design flaw had any impact on how you interpret the outcomes from the study?
Rosalee Shenker
I guess we don’t know. But what I can say is that we had a rigorous post-treatment assessment by telephone that would have revealed all the post-treatment stuttering that was present.
Ann Packman
What are your future research plans? Where are you going from here with the LP for this age group?
Rosalee Shenker
I’m in the same position as those at the Institute for Stuttering Treatment and Research (see Chapter 9). The Montreal Fluency Centre is a specialist treatment unit with very little research funding. What research we can do is thanks to the generosity of the clinicians that work with me and spend their time willingly evaluating these programmes. That aside, I think that one of the things that I would like to do is a prospective study of the LP with school-age children but with a more comprehensive set of measures, particularly including non-speech measures. I would also like to trial the LP against one of the more traditional therapies. I am also interested in the language abilities of these older children and how that might affect treatment outcomes, along with cognitive capacity.
Joseph Attanasio
Do you have any idea why that one child worsened after treatment?
Rosalee Shenker
Yes, it was parent compliance. The parent stopped providing the verbal contingencies during Stage 2. Commonly, that may cause stuttering to increase and that is what happened on this occasion.
Joseph Attanasio
Is it true that child finished up with more severe stuttering than before treatment?
Rosalee Shenker
Yes, that is the case, but I am not sure it could be attributed to the LP.
Sheena Reilly
Given that the LP has been around for quite some time, our group were intrigued with why it has not been trialled much with school-age children. Is it just simply that it’s promoted as a programme for young children and nobody has been adventurous enough to do it with school-age children?
Rosalee Shenker
I haven’t really thought about it. In my experience many clinicians are happy to try it with that age group, but I have certainly heard little about plans by researchers for prospective clinical trials.
Ann Packman
We were wondering about what effect the positive attention to speech might have. Could that be part of the treatment effect, possibly a major part?
Rosalee Shenker
It is true that the LP causes parents to spend more quality time with their children with all kinds of novel activities. Parents tell us that it encourages them to enjoy their children, and the children certainly benefit from this different kind of attention. But to what extent that is a treatment effect is an empirical question. I don’t think it is possible to know any other way but with experimentation.

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1 Since the date of the symposium, members of the Lidcombe Program Trainers Consortium met in Philadelphia during November 2010. On the agenda of that meeting was consideration of a growing number of reasons for considering that %SS should be deleted as a mandatory component of the treatment guide. The Consortium decided to make this change and the current version of the treatment guide outlines the new procedures (Packman et al., 2011). The rationale for the treatment is outlined in Bridgman et al. (2011).

2 See footnote on p. 58. The current Packman et al. (2011) treatment guide excludes measures of %SS as a criterion for Stage 2 entry and progression.

3 The Koushik et al. (2009) report states nothing about the treatment history of the children.

4 Onslow et al. (2001) also reported linguistic data for two school-age boys whose stuttering was controlled with time-out during a previous laboratory study. During time out conditions, one boy reduced his language complexity and one did not.

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