Lidcombe Program for stuttering for children intervention

Lidcombe Program for stuttering

2. Stuttering treatment in the
preschool years: The
Lidcombe Program

3. @RachaelUnicomb
Dr Rachael Unicomb, Senior Lecturer
Email: [email protected]

4. Treatments approaches for
early stuttering
•Multi-factorial Model: Multiple factors attributed to child’s stuttering including
physiological, linguistic, psychological, environmental
–RESTART DCM
–Family focused (e.g., Palin Parent-Child Interaction Therapy)
•Speech Restructuring: Method of speaking using a novel speech pattern to facilitate
fluency
–Smooth speech
–Syllable timed speech (e.g., Westmead Program)
•Verbal Response Contingent Stimulation: Verbal feedback in provided contingent
on stutter-free or stuttered speech
–Lidcombe program
–Westmead Program (?)

5. Verbal Response
Contingent Stimulation
Treatments
•Early VRCS treatments
–The Lidcombe Program of Early Stuttering Intervention

6. The Puppet Study
(Martin et al., 1972)
•Participants were 2 preschool stuttering children
•A puppet was mounted in an illuminated box
•The puppet disappeared when the child stuttered
•Pre and post treatment measures were obtained
•Beyond clinic recordings were obtained
•For both children, frequency of stuttering was greatly reduced, results
generalized to everyday speaking situations
•Classified as a Phase I clinical trial (Onslow et al., 2008)

7. The Lidcombe Program of
Early Stuttering
Intervention
•Onslow, Packman & Harrison (2003) early text-book; however:
•Treatment Guide available on ASRC website
•Behavioural program developed by clinicians and researchers
•Verbal contingencies delivered to child by parents
•Based on weekly clinic visits
•Two stages: Clinical period and Maintenance
•Goals of Stage 1: No stuttering (or almost no stuttering)
•Goal of Stage 2: No stuttering (or almost no stuttering) for a long period of time

8. The Lidcombe Program: An
evidence-based program for
early stuttering

9. Does the Lidcombe
Program work?
According to the Clinical Trials Definition by Onslow and colleagues
(2008)…
There are 15 Lidcombe Program treatment clinical trials for preschool
children (incl. telehealth trials):
•7 Phase I Trials
•5 Phase II Trials
•3 Phase III Trials

10. Phase I clinical trials
Seven Phase I Trials
•Onslow et al., (1990)
•Harrison et al., (1999, telehealth)
•Wilson et al., (2004; telehealth)
•O’Brian et al., (2014; telehealth, webcam)
•Vong et al., (2016)
•Al-Khaledi et al., (2017)
•Unicomb et al. (2017; co-occurring SSD)
Have reported or estimated an effect size of greater than 90% reduction
of stuttering

11. Phase II clinical trials
Five Phase II Trials
•Onslow et al., (1994)
•Lincoln & Onslow (1997)
•Rousseau et al., (2007)
•Lewis et al., (2008, telehealth)
•Koushik et al., (2019)
Again, all of these trials reported an effect size of greater than 90%
reduction of stuttering

12. Phase III clinical trials
Three Phase III Trials (RCTs)
•Jones et al., (2005)
•Arnott et al., (2014, Group service delivery)
•Bridgman et al., (2016, Webcam)
Have reported or estimated an effect size of greater than 90% reduction
of stuttering

13. Translational Research
•Effectiveness studies
•Phase IV trials
•Extent to which outcomes of clinical trials can be achieved in community clinics
(O’Brian et al. (2013)
•Mean %SS 9-months post-treatment was 1.7%. However, clinicians who had been
trained in the use of the LP attained means of 1.1%SS.
AND
•Rappell et al., (2017)
•O’Brian et al., (2022)

14. Data-based case studies
and clinical experiments
•8 data-based case studies use of LP in other cultures/countries
–Malaysia
–Kuwait
–Iran
–The Netherlands
–Sweden
–China
–Bulgaria
•3 randomised clinical experiments
–Lattermann et al. (2008) – 16 weeks of LP
–Harris et al. (2002) – 12 weeks of LP
–Franken et al. (2005) – 12 weeks of LP + multifactorial treatment

15. Meta-analysis
•Systematic review of meta-analysis for many RCTs
•Highest level of research
•Not yet possible for clinical trials of stuttering
However – meta-analysis of randomised clinical evidence for LP involving no-treatment
control group
•Includes evidence from four studies involving 134 children in total
•At a mean post-randomisation period of 6.3 months, LP did better than control
children. LP odds ratio was 7.5 for achieving below 1%SS at post-randomisation.

16. Wait…there’s more!
•Research investigating other variables including:
–Clinical trials comparing LP to other treatment approaches
(including the largest Phase III RCT reported for any stuttering
treatment)
–Therapist drift
–Mechanisms of action
–Treatment safety
–How long treatment takes
–Does delaying treatment affect treatment process
–Case variables affecting treatment
–Parental experiences/perceptions

17. Does TELE-HEALTH
adaptation work?
•COVID and children isolated from services
•Low- or high-tech replacement of in-clinic contact
•Zoom/Skype/Webcam
•Three Phase I trials (Harrison et al. 1999, Wilson et al. 2004, O’Brian, 2014)
•One randomised Phase II trial (Lewis et al., 2008)
•One RCT Phase III (Bridgeman et al, 2016)
•All children in the studies reduced stuttering
•However, three times the resources (MORE clinical hours) were required than in-clinic
sessions
•Conclusion, telehealth treatment is a viable treatment option for families unable to access
services

18. Lidcombe program:
treatment goals
key components
stages
outcomes

19. 19What does the Lidcombe
Program look like?

20. What type of treatment
is the LP?
•A treatment developed by clinicians and researchers
•An evidence-based treatment
•A behavioural treatment
•A treatment that is done by parents

21. What is the goal of the
LP?
•STAGE 1 = No stuttering (or nearly no stuttering)
•STAGE 2 = No stuttering for a long period

22. Stage 1
(Instatement)
Daily home treatment
Response contingent stimulation during
practice sessions and natural
conversations
Weekly clinic visits
Parent training
Collation of stuttering measures
Stuttering Measures
Beyond clinic: severity rating (0-10) daily
Within clinic: severity rating (0-10) weekly
%SS weekly (optional only)
Stage 2
(Maintenance and monitoring)
Time between clinic visits increases,
contingent on maintenance of stuttering
severity criterion
On-line response contingent stimulation as
required
Stuttering severity decreased to criteria

23. Key components of
the LP
•Active treatment / Instatement (Stage 1)
•Maintenance (Stage 2)
•Clinical measurement of stuttering
•Verbal contingencies during conversation
•Parent training

24. Child responses in the
LP
•Essential
–Stutter-free Speech
–Unambiguous Stuttering
•Non-essential
–Spontaneous self-evaluation of speech
–Spontaneous self-correction of stuttering

25. Parent Training
•Verbal contingencies
•Applied to the essential
responses during conversations
•Not constant, intensive or
invasive

26. Parental Verbal
Contingencies
CHILD’S
RESPONSES
Stutter-free
speech
Unambiguous
stuttering
PARENTAL
VERBAL
CONTINGENCIES
Praise Acknowledge
Request
self-
evaluation
Request
self-
correction

27. For stutter-free speech:
•Acknowledge
•Praise
•Request self evaluation
For stuttering:
•Request self-correction
•Acknowledge
What would you say?
(1) Stutter-free Speech
(2) Stuttering

28. How are parental verbal
contingencies
implemented?
•Weekly 1-hour clinic visits to the speech pathologist
•Individualised for each child
•Practice sessions and natural conversations
Parent training
•Parents do the treatment, so they have to learn how to deliver treatment at
home
•Parent training changes as the treatment changes

29. Treatment in practice
sessions
•First conversations are carefully structured by the parent for optimal learning
to occur
•Verbal contingencies taught to be presented correctly
•Verbal contingencies taught to be presented safely
•The child has to accept and enjoy the verbal contingencies
•Treatment must be fun ☺

30. Treatment in natural
conversations
•At the start of the program parents give the treatment in structured conversations only
•Subsequently, parents give the treatment in the unstructured conversations of daily life
–Talking at the dinner table
–Talking about what happened at school
–Conversations playing at the park
•For a period, treatment occurs in both practice sessions and natural conversations (structured
and unstructured conversations) concurrently
•Treatment in practice sessions (structured) conversations stops when it is no longer necessary

31. Measurement
•Parent and clinician need to monitor treatment effects and adjust therapy
•The best way to do this is with a convenient and quick measurement system
•Beyond clinic severity rating (SR)
0 = no stuttering, 2 = extremely mild stuttering, 10 = extremely severe stuttering
•Optionally, SRs supplemented with within clinic percentage syllables stuttered
(%SS)
•Program criteria: 0-1 SR’s both within and beyond-clinic for 3 consecutive
weeks (with more 0’s than 1’s)

32. 32

33. What might a Stage 1
clinic visit look like?
Duration Activity
10 minutes A language sample is conducted with the child, based on conversational speech if
possible (unstructured)
3 minutes Clinician and parent give sample a SR and discuss this in detail
10 minutes Clinician collects parents daily SRs for the previous week and has lengthy discussions
about these results
5 minutes Clinician and parent discuss treatment in general for the previous week
10 minutes Parent demonstrates treatment procedures for past week
2 minutes Clinician gives parent feedback and discusses changes for coming week
5 minutes Clinician demonstrates these changes to parent with the child
5 minutes Parent asked to demonstrate these changes with the child
5 minutes Clinician summaries feedback and home expectations for coming week

34. How do we know the
treatment is working?
•Monitor progress weekly using parental daily SR scores
•Expect mean 30% change in SR scores during the first four weeks of treatment
(Onslow, Harrison, Jones & Packman, 2000)
•If this does not happen, need to problem solve (something might be wrong)
–Review:
–Lidcombe Program Checklist (Canvas)
–Challenges and Strategies for SLPs using the LP (Canvas)

35. How long does treatment
take?
One prospective regression study
•Rousseau et al., 2007
•Median treatment time to stage 2 approximately 16 clinic visits
Three retrospective recovery plot/regression studies
•Jones, Onslow, et al., 2000
•Kingston, Hayhow, et al., 2003
•Koushik, Hewat, et al., 2011 (meta analysis)
–444 children completing Stage 1
–Median clinic visits to complete Stage 1 was 11
Most recent study (Guitar et al., 2015)
•15 children retrospectively treated with LP, and a further 14 CWS
•Median clinic visits to complete Stage 1 was 15
•Children who stuttered more frequently and severely may take longer in LP treatment

36. What might a Stage 2
clinic visit look like?
Duration Activity
10 minutes Language sample collected – primary aim to determine that criterion for stage 2 is
retained
1 minute Clinician and parent give this sample a SR and discuss
1 minute Parent gives SRs for previous week (only collected week prior to appt)
5 minutes General discussion about child’s speech and the SRs previously given
5 minutes Discussion of therapy since last appointment in detail and what action the parent took
if stuttering occurred
5 minutes If child not meeting criterion, discuss possible actions
5 minutes If child meeting criterion, discuss systematic withdrawal of treatment
1 minute Schedule next stage 2 visit (if appropriate)

37. The Lidcombe Program
Stuttering Measures
10
9
8
7
6
5
4
3
2
1
Leon
04 26 05 03 05 10 05 24
05 31 06 07 06 14
07 05 07 12
U T A
U T AU T A
10
9
8
7
6
5
4
3
2
1
10
9
8
7
6
5
4
3
2
1
10
9
8
7
6
5
4
3
2
1
Parent Severity
%SS
10
9
8
7
6
5
4
3
2
1
10
9
8
7
6
5
4
3
2
1

38. Handy resources
Australian stuttering research centre website (Lidcombe Program resources):
https://www.uts.edu.au/asrc/resources/lidcombe-program
➢Lidcombe Program brochure and treatment guide
➢Lidcombe program severity rating chart
➢Stuttering treatment activity guide
➢Problem solving in the Lidcombe Program
Lidcombe Program Trainers Consortium website:
https://www.lidcombeprogram.org/
➢Information for families and caregivers
➢Information for SLPs
➢Information for teachers and other health professionals
More extensive information on the Lidcombe Program (and stuttering generally):
Stuttering and it’s treatment – 12 lectures (e-book): Twelve Lectures 2024-01-19 (uts.edu.au)

39. THANK
YOU