2003 IFA Congress: Montreal, Canada

Responsiveness to Treatment of Early Stuttering with the Lidcombe Program: Preliminary Results

Isabelle Rousseau1, Ann Packman1, Mark Onslow1, and Elisabeth Harrison2
1Australian Stuttering Research Centre, The University of Sydney, PO Box I 70, Lidcombe NSW 1870, Australia
2Department of Linguistics, Macquarie University NS W 2109, Australia


SUMMARY

This paper reports an investigation into the relationship between time since onset of stuttering and the duration “of treatment with the Lidcombe Program. The Lidcombe Program of early stuttering intervention is a parent-delivered behavioural treatment. In the past, time since onset has been associated with duration of treatment and these findings are important for deciding whether to begin treatment or to delay treatment to give a chance for natural recovery to occur. However, existing studies are methodologically limited by retrospective methods. The present project incorporates prospective methods, and preliminary data are presented.


  1. Introduction
The current study explores whether the interval between onset of stuttering and start of treatment relates to time taken to complete Stage 1 of the Lidcombe Program. The Lidcombe Program is a behavioural treatment for stuttering preschool-age children (see Onslow et al., 2003) developed in Australia. Recovery plot data have been independently replicated (Jones et al., 2000; Kingston et al., 2003). Phase I and Phase II clinical trials are complete, and a Phase III randomised controlled trial is nearing completion at the time of writing (Jones et al., 2001).

There are currently competing findings relating to onset-to-treatment interval and responsiveness to stuttering treatment. Starkweather and Gottwald (1993), in a file audit of children treated with the Multiprocess approach (see Gottwald & Starkweather, 1999), found these variables to be positively associated, suggesting that treatment took longer in children who had been stuttering for longer. Because of this relationship, although modest (r = .44), the authors argued that treatment should begin as soon as possible after parents become concerned. However, in a retrospective file audit of 250 children treated with the Lidcombe Program, Jones et al. (2000) found a trend in the opposite direction although the relationship between longer onset-to-treatment interval and shorter treatment time was not statistically significant. Kingston et al. (2003) then conducted a meta- analysis of these data with those of another file audit based on an independent cohort of subjects in the UK. The trend in question was confirmed and statistical significance was achieved for the total of 316 subjects. Preschool-age children who had been stuttering for more than 12 months took significantly less time to progress through the program than children who had been stuttering for less than 12 months.

The pursuit of establishing whether the onset-to-treatment interval is related to duration of treatment is of prime importance for intervention planning with children who stutter. It is now known that a considerable proportion of children recover spontaneously from stuttering. Recovery estimates from the general population range from 75% to 89% (Andrews & Harris, 1964; Mansson, 2000; Yairi & Ambrose, 1999). If the Starkweather and Gottwald (1993) data are correct, then delaying treatment in the hope that spontaneous recovery might occur would mean that stuttering becomes less tractable and that treatment takes longer. On the other hand, if the Jones et al. (2000) and the Kingston et al. (2003) data are correct, then delaying treatment for a short period, at least during the preschool years would not affect treatment responsiveness and would maximise the chance of natural recovery. Such a delay would in fact be desirable.

Existing studies of the issue with the Lidcombe Program have relied on retrospective file audits. The weakness of this method is that the time of stuttering onset was not established using a standard protocol and was collected from the second-hand source of file entries. The data presented here are part of a larger study in progress, which involves treatment of a large cohort of children.

Prospective methods are incorporated, using a standard protocol to determine the time of stuttering onset (Yairi & Ambrose, 1992).

  1. Method
Subjects

Subjects admitted into the ongoing study are recruited from a treatment waiting list of a local public health clinic. At an initial assessment, children are referred to the study if they are diagnosed as stuttering and have stuttering as the main area of concern. When their names come to the top of the waiting list, they are reassessed with the research protocol (see Assessment) and are admitted into the study if the research clinician confirms the presence of stuttering. All subjects are then diagnosed as stuttering by two speech pathologists and must meet the following inclusion criteria: (a) age between 3 and 12 years, (b) English as a main language, (c) stuttering for at least three months, (d) stuttering rate above one percent syllables stuttered (l%SS), (e) no therapy for stuttering in the last 6 weeks. Data on the first 27 preschool-age subjects who completed Stage 1 of the treatment program (see TreatmentPr0cess) are reported here. Table 1 presents their ages, genders, onset-to- treatment intervals and the number of Stage 1 (see below) treatment sessions completed. There were 20 boys and 7 girls, aged between 3 years and 5 years 7 months. All subjects started treatment before they were 6 years of age. All but four subjects had reported family history of stuttering. Their onset-to-treatment intervals ranged from 4 to 25 months (Mean = 12.7 months). Mean age and mean stuttering rate at the first treatment session were 46.4 months (SD = 7.6 months) and 2.7 %SS respectively. The average waiting time between the first assessment and the first treatment clinic visit was 5.4 months.

Assessment

Assessment occurs during two clinic visits. In an interview with one or both parents, the clinician obtains relevant case history information using a standard protocol to establish time of stuttering onset (Yairi & Ambrose, 1992). Assessment also includes testing of expressive and receptive language and phonological development. Standardised tools are used, such as the Peabody Picture Vocabulary Test ~ Third Edition (Dunn & Dunn, 1997), the Clinical Evaluation of Language Function -- Preschool (Wiig, Secord & Semel, 1992) or the Clinical Evaluation of Language Function - Third Edition (Semel, Wiig & Secord, 1995) and the Assessment of Phonological Processes - Revised (Hodson, 1986). During the three-week assessment period, six 10-minute speech samples are collected beyond the clinic and three are collected within the clinic. Treatment commences once all pretreatment data have been collected.

Treatment Process

This study is conducted in a public health clinic. Lidcombe Program treatment is delivered by parents in the child’s everyday environment, and is conducted in two stages. During Stage 1, the parent and child come to the clinic each week for 45 to 60 minutes. During these visits, the parent learns to conduct the treatment. When there is a very low level of stuttering or no stuttering 186 Theory, research and therapy in fluency disorders both inside and outside the clinic over three weeks, the child then moves to Stage 2 of the program. During Stage 2, visits are less frequent and clinic attendance decreases contingent on long-term maintenance of program criteria. For a detailed description of treatment procedures the reader is referred to Onslow et a1. (2003). Time taken to complete Stage 1 varies between children. Jones et a1. (2000) reported that their subjects took a median of 11 clinic visits to complete Stage 1.

RTT_t1.png

Table 1. Gender; age at first Stage 1 clinic visit, time since onset of stuttering at first Stage 1 clinic visit and number of clinic visits to complete Stage I for all 27 subjects.

  1. Results
Subjects completed Stage 1 in a median of 16 clinic visits, with a minimum of six and a maximum of 40. A simple regression was conducted to assess whether onset-to-treatment interval correlated with treatment time and results are displayed in Figure l. The regression plot (r = -.19) illustrates a slight negative correlation which is not sta:istically significant. None :heless, there appears to be a trend in the same direction as the Jones et al. (2000) data, suggesting that a longer onset-to-treatment interval could be associated with a slightly shorter treatment time. No correlation was found between age at the first treaiment session and the number of visits in Stage 1 (r = .008).

RTT_f1.png

Figure 1. Regression plot of the number of Stage 1 visits and the onset-to-treatment interval in months. Each circle represents one subject.

  1. Discussion
The children in this study took slightly longer to complete Stage 1 than reported in previous studies of the Lidcombe program. One reason for this is may be that children with very mild stuttering (1%SS or below) were not accepted into this prospective study, whereas many such children were included in the previous file audit studies. Jones et al. (2000) found that %SS predicts treatment time. The lack of correlation between age and duration of treatment in the present study is consistent with previous reports (Kingston et al., 2003), and the absence of a significant correlation between onset-to-treatment interval and the number of visits in Stage 1 is consistent with Jones et al. (2000). The trend in the present findings for children who have been stuttering longer to take less time in treatment is consistent with the significant finding of Kingston et al. (2003). However, this is clearly a very small effect. Clinically, then, time since onset cannot be used confidently to predict how long treatment will take with the Lidcombe Program. While the increased statistical power of the meta-analysis conducted with the Jones et al. (2000) and the Kingston et al. (2003) data resulted in a significant correlation between those variables, these reports individually failed to reach statistical significance. This could suggest that even though there is a trend suggestive of a relationship (also found in this study), considerably higher subject numbers are needed to detect a significant effect, at least with a retrospective methodology. It remains to be seen whether this effect will be present when many more children have been recruited to this rigorous study, which uses prospective methodology and a standard protocol to reliably determine time of stuttering onset.

These preliminary data again indicate a difference between the Lidcombe Program and the Multiprocess approach in terms of time since onset of stuttering. Children who have been stuttering for longer take more time to complete the Multiprocess approach, whereas this is not the case for the Lidcombe Program. The reason for this is unknown, but it is likely related to the fact that the treatments are completely different. The Multiprocess approach relies primarily on changing the child’s environment, but in the Lidcombe Program, stuttering and stutter-free speech are targeted directly. In any event, it would be incautious to generalise findings of predictors of treatment time from one type of treatment to another.

Finally, in order to balance the chance of natural recovery against minimising treatment time, these data suggest that clinicians faced with deciding when to begin treatment with the Lidcombe Program will need to base their decision on factors other than time since onset. Such factors may be stuttering severity, whether severity decreases over time, age and level of distress of the child (see Packman, Onslow & Attanasio, 2003 for a detailed discussion).

References
Andrews, G., & Harris, M. (1964). The syndrome of stuttering. Clinics in Developmental Medicine, No. I 7. London: Heinemann.

Dunn, L.M. & Dunn, L.M. (1997). Peabody Picture Vocabulary Test (PPVT III) - Third Edition. Circle Pines, MN: American Guidance Service.

Gottwald, S.R. & Starkweather, C.W. (1999). Stuttering prevention and early intervention: A multiprocess approach. In M. Onslow & A. Packrnan (Eds.) The handbook of early stuttering intervention (pp. 53-82). San Diego, CA: Singular.

Hodson, B.W. (1986). The Assessment of Phonological Processes - Revised. Austin, TX: Pro-Ed.

Jones, M., Gebski, V., Onslow, M., & Packman, A. (2001). Design of randomized controlled trials: Principles and methods applied to a treatment for early stuttering. Journal of Fluency Disorders, 26, 247-267.

Jones, M., Onslow, M., Harrison, E., & Packman, A. (2000). Treating stuttering in children: Predicting outcome in the Lidcombe Program. Journal of Speech, Language, and Hearing Research, 43, 1440-1450.

Kingston, M., Huber, A., Onslow, M., Packman, A., & Jones, M. (2003). Predicting treatment time with the Lidcombe Program: Replication and meta-analysis. International Journal of Language and Communication Disorders, 38, 165-177. '

Mansson, H. (2000). Identification of stuttering in preschool children -A multifactorial, longitudinal study in development. Journal of Fluency Disorders, 25, 47-57.

Onslow, M., Packman, A., & Harrison, E. (Eds.). (2003). The Lidcombe Program of early stuttering intervention: A clinician’s guide. Austin, TX: Pro-Ed.

Packman, A., Onslow, M., & Attanasio, M. (2003). The timing of early intervention with the Lidcombe Program. In M. Onslow, A. Packman, & E. Harrison (Eds.) The Lidcombe Program of early stuttering intervention: A clinicians guide (pp. 41-55). Austin, TX: Pro-Ed.

Semel, E., Wiig, E.H. & Secord, W.A. (1995). Clinical Evaluation of Language Fundamentals, Third Edition. San Antonio, TX: The Psychological Corporation, Harcourt Brace J ovanovich.

Starkweather, C., & Gottwald, S. (1993). A pilot study of relations among measures obtained at intake and discharge in a program of prevention and early intervention for stuttering. American Journal of Speech-Language Pathology, 2, 51-58.

Wiig, E.H., Secord, W. & Semel, E. (1992). Clinical Evaluation of Language Fundamentals- Preschool. San Antonio, TX: The Psychological Corporation, Harcourt Brace J ovanovich.

Yairi, E., & Ambrose, N. (1992). Onset of stuttering in preschool children: Selected factors. Journal of Speech & Hearing Research, 35, 782-788.

Yairi, E., & Ambrose, N. G. (1999). Early childhood stuttering I: Persistency and recovery rates. Journal of Speech, Language, & Hearing Research, 42, 1097-1112. Section 4. Outcomes and Efiicacy of Interventions I 89

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