The Lidcombe Program

Advantages and disadvantages

Advantages

In relation to other early stuttering interventions, the evidence base for the LP is generally acknowledged as strong, and with more evidence to support its use than any other early intervention (Bloodstein and Bernstein Ratner, 2008; Bothe et al., 2006; Kalinowski and Saltuklaroglu, 2006; Yairi and Ambrose, 2005). Two qualitative studies report positive experiences by parents who use the LP. Goodhue et al. (2010) reported maternal experience of increased quality time with their stuttering children and improved parenting skills during the course of treatment. Mothers also reported increased knowledge of stuttering and its management as a benefit of the programme. Parents reported that their children enjoyed the verbal contingency procedures and the clinic visits.

Hayhow (2009) reported that when children made steady progress, mothers found using the LP with their children straightforward, and some expressed surprise that such simple procedures could have such a positive effect. These parents were enthusiastic and innovative with a capacity for independent problem solving. However, Hayhow reported a group of parents for whom treatment progress was initially straightforward, and then the treatment process became somewhat problematic. Hayhow also reported a minority of parents whose treatment was difficult from the outset. These parents found the verbal contingencies difficult to manage, experienced problems in leading the child through activities and did not develop the problem-solving skills that were apparent in the straightforward group. These parents held some beliefs about childhood stuttering that made the treatment problematic for them.

Clinicians have reported that the LP encourages an open attitude towards stuttering in both parents and children who nearly always become more comfortable about stuttering (Hayhow, 2005). The same clinicians also reported that they and many parents liked being actively involved in treatment, and felt empowered by knowing specifically how to handle the problem. This could be linked to treatment happening where stuttering occurs, during everyday conversations. It may also be linked to the fact that the LP in no way implicates parents in the cause of stuttering or its perpetuation. Stuttering reduction without altered speech patterns is arguably one of the advantages of the LP (Hayhow, 2011).

Disadvantages

There are several components of the LP specified in the treatment guide (Packman et al., 2011) and it is unknown, which of them are essential to any treatment effects and which are not. At present there is only sketchy and preliminary evidence about the matter. Harrison et al. (2004) provided some suggestion that the verbal contingencies for stuttered speech might be essential and that parent severity ratings might not. Koushik et al. (2011) provided preliminary evidence that clinic visits each week might not be essential. The Lidcombe Program Trainers Consortium deliberated about whether clinicians measuring %SS within the clinic was an essential treatment component, and decided it was not (Bridgman et al., 2011; see Footnote p. 44).

At present no mechanism is known for why the LP might work. Although the LP is not driven by causal theory, as described previously, that of course does not stop speculation about the mechanisms by which it might be able to control early stuttering. At present, those mechanisms are unknown, with some evidence that post-treatment acoustic changes are not responsible (Onslow et al., 2002), and some evidence that frank change of children’s language function is not involved either (Bonelli et al., 2000; Lattermann et al., 2005). There is some suggestion that the LP may facilitate whatever mechanism might be responsible for natural recovery (O’Brian and Onslow, 2011).

During the period of its development, understanding of possible causal factors for stuttering has increased. There is now evidence of subtle differences in brain structure (e.g. Brown et al., 2005; Sommer et al., 2002) and evidence of differences in brain functioning affecting speech motor control (Alm, 2004; Packman et al., 2007; Smith et al., 2010). Those differences appear to exist with school-age children who stutter (Chang et al., 2008). Should those differences be involved with stuttering causality, speculation is possible that children might learn a ‘work-around for that neuroanatomical problem’ (Onslow and Yaruss 2007, p. 67). Indeed, a constructivist view of the matter is that children are actively engaged in making sense of their experiences (Butler and Green 2007). From this perspective, requests for self-correction provide a protected space within a conversation where children can experiment with more effective ways of managing their moments of stuttering, which cannot be done during usual childhood conversation. Bernstein Ratner and Guitar (2006) discuss a range of effects that the LP might have on parents, such as reducing anxiety about stuttering and providing supportive speech attention. These are among many potential explanations for documented treatment effects that might attribute them to factors other than, or in addition to, the verbal contingencies.

The LP has been associated with potential negative parent experiences. Goodhue et al. (2010) and Hayhow (2009) reported that parents could experience guilt because of feeling that they are not doing the treatment properly. Hayhow specifically sought a group of parents for whom treatment was not proceeding satisfactorily, and found certain associated case history features. These included a strong family history of stuttering, other speech and language problems, learning difficulties or co-morbid diagnoses of dyspraxia or other motor problems. Such parents require more support when treatment takes longer.

Children as young as 2 years may be aware of their stuttering and some may be distressed by it (Boey et al. 2009). Preschool children may suffer negative social consequences when they stutter in front of their peers (Langevin et al., 2009). However, there is some evidence that LP treatment might not be as suitable for younger children as it is for older children (Jones et al., 2000; Kingston et al., 2003) and so there is a tension between allowing time for natural recovery to take its course and protecting children from potentially harmful peer responses and negative self-evaluation.

Conclusions and future directions

The LP has come a long way since its early development by Onslow and colleagues in Sydney. It is now widely used in many countries and there is an increasing evidence base. Quantitative studies have helped to establish its effectiveness and safety and qualitative studies have helped us understand more of the experiences of the parents and clinicians who use the programme. Future research may help us work more effectively with challenging cases and continued refinement of the treatment should ensure that the programme remains a viable treatment option in the future.

Current and future developments of the LP are geared to improve access to the treatment by increasing its availability and its clinical efficiency. With regards to the former, a series of trials of the treatment in telehealth format provides potential for it to reach families who have no local services or who are unable to attend their nearest clinic (Harrison et al., 1999; Lewis et al., 2008; Wilson et al., 2004). Results generally show that such a treatment format requires twice as long for the completion of Stage 1, however current developments of webcam technology might be expected to improve that situation. A randomised controlled trial of the LP with in-clinic presentation and webcam presentation is currently being investigated. The trial is a collaboration between La Trobe University in Melbourne, Australia, and the Australian Stuttering Research Centre in Sydney, Australia. Such developments might eventually lead to a useful stepped care model of early intervention.3 With regards to treatment efficiency, a randomised controlled clinical trial of group treatment has been completed (Lees et al., 2011). The collaborating centres for that trial are the same as for the webcam trial mentioned previously.

With regards to increasing clinical efficiency there is much to learn about what parents actually do in home treatment and in trying to establish which aspects of the programme are essential for progress. A preliminary study of what parents actually do has been published (Carr-Swift et al., 2011). Mixed method studies may add to our understanding of the essential treatment components (Hayhow, 2011) and so lead to more efficient treatment.

Finally, an international translational research programme of the LP is under way in Australia, North America and the United Kingdom, for the purpose of determining to what extent community clinicians can match the results that have been attained in clinical trials. The first results from the Australian part of that research have been completed (O’Brian et al., 2011) and at the time of writing, a paper based on those results is in peer review.

Discussion

Sheena Reilly
A critical issue our group came up with is whether there is any danger if parents request self-corrections of the wrong behaviours, if they use verbal contingencies for stutter-free speech?
Rosemarie Hayhow
It can happen of course if they mistake stutter-free speech for stuttering. It is more likely to happen when the treatment starts to be successful and parents focus on normal disfluencies. What often happens, in my experience, is that parents will say ‘I’ve noticed he has started saying whole words a couple of times’ when in fact there is no reason to think that might be stuttering. But then parents often say, ‘but I started looking at other children and I’ve noticed they’re doing it too’. This is one of the reasons why the LP instructs parents only to use verbal contingencies for unambiguous stuttering and to ignore speech events when there is any doubt. As we say during Lidcombe Program Trainers Consortium teaching, ‘if in doubt, leave it out’.
Sheena Reilly
Would the clinician ensure that parents do this correctly?
Rosemarie Hayhow
Yes, absolutely. The treatment guide specifies that at each clinic visit parents demonstrate to the clinician how they have been presenting the verbal contingencies. So the clinician does watch the process closely. We never ask parents to do things that we don’t see them do in the clinic first. If parents were making any errors with their requests for self-correction, or any other verbal contingencies, a clinician would be expected to pick that up.
Ann Packman
Our primary question is why does it work? You presented various alternatives, but what do you think?
Rosemarie Hayhow
Of course we don’t know at present. As we say during Lidcombe Program Trainers Consortium teaching, one explanation is that the verbal contingencies provide stimulus control. But that really is not a deep explanation neither is what I said about providing a safe environment in which a child can experiment with dealing with their moments of stuttering. That can’t happen in everyday conversation, but when we say ‘would you like to smooth that out’ it encourages children to find their own way of dealing with it. We certainly are not telling them to change their speech pattern or to slow down. Preschoolers have some neural plasticity remaining with speech motor development, and perhaps the treatment capitalises on that. By encouraging children to self-correct we are reducing the opportunities for practising stuttering, this may also be an important factor.
Joseph Attanasio
You said the LP is not based on a putative cause of stuttering itself. Perhaps it is based on motor learning theory?
Rosemarie Hayhow
It was not based on motor learning theory, but that might explain why it works. It certainly works differently from the indirect treatment for preschoolers we will hear about and discuss tomorrow (see Chapter 13). I think there is a difference, a very important difference. With the LP we are inviting children to learn how to deal with these little glitches that are happening in their speaking and so we are encouraging them to take a very active role in the management of that problem, rather than hoping that by creating a facilitating environment the child will develop through a period of stuttering. Feedback plays an important role in motor learning and parental contingencies provide the children with specific feedback. This feedback helps them distinguish between stuttered and stutter-free speech. Initially, during the talk-times, parents give frequent contingencies but then as treatment progress the children increasingly rely upon their internal feedback mechanisms. This process of a gradual shift from external to internal feedback is consistent with motor learning theory.
Ann Packman
I have an interesting question for you from the group. Why after so long and with so much evidence, is there still so much controversy about the LP.
Rosemarie Hayhow
I don’t understand it. I think many still see the LP as a cold programme, and I don’t think that idea goes away until clinicians have Lidcombe Program Consortium training and discover that it is a supportive and child-centred treatment. It may also be the case that indirect treatments are based on complex models of what causes early stuttering, and there are many who believe those models to be correct and that a complex problem requires complex assessment and treatment. I suppose it is a different way of thinking about early stuttering, that it can be managed by something as simple as verbal contingencies, I also think behavioural treatments got a bad reputation around the 1970s and they were seen as taking a limited view of the problem, as clinically ‘cold’ and not suitable for small children. But the Goodhue et al. (2010) and Hayhow (2009) studies indicate this not necessarily the case for the LP. These reports also show that things don’t go well for parents if the treatment is not going so well, but that would be expected for any treatment.
Sheena Reilly
My group was interested in any comments you can make on the characteristics of children that you wouldn’t use the LP with, and if so what were they like? And are there any predictors of which children do better? We talked about possible factors such as age of the child, the type of family and temperamental characteristics.
Rosemarie Hayhow
The Jones et al. (2000) and Kingston et al. (2003) file audit reports showed that little could predict how long Stage 1 treatment took. More severe stuttering pre-treatment was related to slightly longer treatment times, and very young children shortly after onset also required more clinic visits. That was intuitive to us because the LP makes cognitive demands of children. Now there are clinical trials data about an even simpler treatment that would be suitable for very young children, that gives an alternative to consider in those situations (see Chapter 15). I am now participating with colleagues from Australia and the United Kingdom in the translational research I mentioned. That research is designed to determine features of children and parents – such as their psychological and temperament status – clinician training and clinical workplaces that might impact on how well the treatment goes. From a clinically anecdotal viewpoint, a number of factors recur for us. Children who have additional speech and language problems, a very strong family history of stuttering, dyspraxia and learning difficulties are going to take longer and may not achieve low levels of stuttering. Another problem group is children who have stuttering and cluttering, where a reduction in frequency and severity of stuttering often occurs but residual rapid syllable repetitions persist. Otherwise most children seem to do well. Please note though that I am discussing children younger than 6 years, which is the age group for whom the treatment was developed; see Chapter 5 for the Lidcombe Program with school-age children.
Joseph Attanasio
Could you carry on with this discussion to include cultural and multi-cultural issues, parent/clinician culture and culture in general. Do cultural issues ever impair the treatment?
Rosemarie Hayhow
This is so complex. The client population we have in Bristol has many refugee families from different parts of Africa and there are all sorts of reasons why doing something like the LP is difficult with them. I think you need to assess each case on its own merits. I would never want to disregard the LP as an option with a family because they are in difficult circumstances or come from a different cultural background. Some of them have done extremely well. But always we are on the lookout for LP features that are culturally difficult for families, and for those families who have other problems going on at the same time. Margaret Weber, who retired from the Lidcombe Program Trainers Consortium some years ago, used to say, ‘assume nothing’, which I think was good advice. Incidentally, we begin Consortium training by pointing out that clinical trials have shown effects for children all over the world. This includes European countries such as Germany, as well as countries like Iran whose language and culture differ markedly from the Western countries where the programme was developed.
Sheena Reilly
Is the LP the same for each child and parent?
Rosemarie Hayhow
Yes. In as much as the contingencies and the severity ratings are the same. However, for each child and parent the presentation of those standard features will differ. Verbal contingencies during structured conversation will be different from one child to the next because we follow the child’s interests and personality as much as we can. And verbal contingencies during everyday conversations will always differ between parent-child pairs. That is one of the fundamentals of the treatment: the clinician needs to find a way to make measurement and verbal contingencies work in a unique way for every family.
Ann Packman
Another question from our group was at what point would you move on if a child wasn’t achieving the desired target and what would you do move on to a different treatment?
Rosemarie Hayhow
There have been such children, albeit few. If I felt that the LP had achieved as much as it could with a particular child and that there were other things that were standing in the way of the child making further progress then I would address those as best I could with the skills that I have and I think that’s all I have time to say.
Joseph Attanasio
Rosemarie you mentioned that, or you hinted, that there might be non-essential components to the LP. Could you clarify them and tell us what they might be?
Rosemarie Hayhow
I don’t really want to go further than the Harrison et al. (2004) and Koushik et al. (2011) reports I mentioned that raised some prospect that verbal contingencies for stuttered speech may be important, that parent severity ratings may not and that the weekly visit to the clinic may not be optimal. I cannot imagine doing the programme without the severity ratings and wonder whether their lack of importance in Harrison’s study was because she looked only at the first 4 weeks of treatment. As time goes on, many parents use severity ratings in an almost intuitive way to help them decide upon the level of structure for home treatment. Without the severity ratings parents might struggle to make these judgments based on subtle changes in their children’s hour-to-hour and day-to-day talking. They are also a tool for communication between parent and clinician. However, we need to wait until we have enough data to continue to pare things back as we did with in-clinic %SS in the Bridgman et al. (2011) paper and to keep an open mind with regards to improving the treatment experience for children and their parents.

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1 Members of the Lidcombe Program Trainers’ Consortium met in Philadelphia in November 2010. One agenda item was discussion of the removal of %SS as a mandatory component of the treatment. 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 change is outlined in Bridgman et al. (2011).

2 The protocol of the Onslow et al. (1994) report was a randomised controlled trial, however, the children could not be retained in the control group so the results are presented here as a Phase II trial.

3 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, model health care 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. A similar model, specifically developed for early stuttering management is described by Hayhow (2007).

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