Speech and Language Therapy Research Unit, Frerzchay Hospital, Bristol BSI6 LE, UK
This presentation reports on the preliminary findings from a study that aims to explore parents’ experience of the Lidcombe Program (LP), a parent based treatment for early stuttering. A discussion of why this exploration is being undertaken is followed by consideration of some of the methodological issues that are being addressed. Themes that have emerged from six pilot interviews are presented with a brief discussion of how these will inform the next stage of the study.
Within the stuttering literature there is discussion of parents’ needs and of their role with pre- school children. The main areas identiﬁed are asfollows: Information for parents on early stuttering, there are a variety of leaﬂets and protocols to guide the therapist (e. g. Peters & Guitar, 1991; British Stammering Association); Tuition on how to provide a ﬂuency enhancing home environment during the child’s vulnerability to ﬂuency disruption (e.g. Manning 2001); Modiﬁcation.of speciﬁc parental communication behaviours considered instrumental in maintaining stuttering, for example, slowing parental rate of speech, turn taking, pausing times (Rustin et al., 1996; Stewart & Tumbull, 1995); Older children may be taught a slower, more relaxed speech pattern in the clinic and parents then required to model this while talking with their child at home (Ramig & Bennett, 1995). In all of the above approaches there is an assumption that parents are able to make good use of the information or instructions imparted and that their children’s speaking will beneﬁt as a result.
The Lidcombe Program differs from the above approaches in several important ways: Firstly, the parents are responsible for carrying out the therapy and they start Working with their child during the ﬁrst therapy session. The rationale for this arises from the early work that showed that operant techniques can be effective in reducing stuttering in young children in an experimental context (Martin et al 1972). It follows from this work that if early stuttering is an operant like behaviour then Contingencies need to occur in the child’s everyday speaking environment in order that experimental or clinical changes in stuttering are generalised. Parents therefore need to be able to carry out in the home environment, as well as in the clinic, the treatment they see the therapist demonstrate. Secondly, the training and coaching of parents is a crucial part of the program and considerable time is given to this in each therapy session. Training the parent and individualising therapy are time consuming activities. So the focus of the sessions is usually on the child, the child’s speaking and then problem solving around ways of maximising the effectiveness of the therapy. Thirdly, unlike some of the other approaches it is not a part of the program to focus on the parental experiences unless they are relevant to the achievement of the program aims. This does not necessarily mean that the parents’ experiences of therapy are not considered important but rather that in this approach they are not a high priority for exploration.
The discussion so far has considered some of the background to this study but does not answer the question of why I am personally interested in the parents’ experience of the program. There are several motivating factors for me. Firstly, some years ago I developed a strong interest in the experience of stammering and what it means to older clients and to parents. The theoretical justiﬁcation for this arose from Fransella’s (1972) work and her use of personal construct psychology (Kelly 1955) to test the notion that changes in thinking or construing could lead to changes in behaviour. This theoretical framework still inﬂuences my thinking and therapy with older clients. I remain interested in personal meanings and how these inﬂuence behaviour and the behavioural options that might be open to the individual. Secondly, I have children and although they are no longer pre-school I know how different the experience of trying to help each of them has been and continues to be. Over the years, my experiences as a parent have conﬁrmed for me the importance of seeing both child and parent as active contributors to any exchange. Children are rarely passive recipients of their parents’ good intentions. It follows therefore, that parents working directly on their children’s speaking is a potential mineﬁeld. Thirdly, there is a lack of literature on parents and their perceptions of therapy and stuttering. Therapists talk about the importance of parents in stuttering therapy but often the voice is that of the therapists and I am interested to hear the parents’ voices within our literature. I think it permissible to generalise and say that parents are expected to be more involved in their children’s development and education than was the case 50 years ago. Yet our literature has very little about what these changes or new ways of involving parents means to them and to their relationships with their children. Glogowska & Campbell’s (2000) study of parents’ account of their child’s speech and language difﬁculties and therapy shows how much there is to learn from such careful questioning and listening.
- Methodological considerations
The current exploration aims to ﬁnd out more about the ‘lived experiences’ of the parents. It aims for a deeper level of understanding about the therapy process from the perspective of the interviewees and is not guided by existing hypotheses or theories. This study is concerned with eliciting experiences rather than the discovery described above and so in-depth interviews are more appropriate than highly structured interviews or questionnaires (Silverman 2000). The analysis of these interviews will also be different. The aim is not to code the content and then count the frequency with which particular issues or themes arise but rather to describe the range of experiences. As more data are accumulated so the emerging themes can be explored through the interview process.
The ﬁnal part of this presentation is concerned with the six pilot interviews.
The preparation involved clariﬁcation of the research questions. An interview guide was developed by translating these into possible interview questions (Kvale, 1996). For example, there is a research question around the extent of the demands made of parents and so the interview guide lists interview questions that can be asked if this area doesn’t come up spontaneously. The possible questions are; ‘How have you dealt with difﬁculties with the program?’; ‘What keeps you going with the program?’; ‘What helps to keep your child co-operative?’; ‘How do you manage to ﬁnd the time?’.
With this type of interviewing it is accepted that people will make choices about what they say and that the story they tell may different if they were talking to someone else or if the purpose of the interview was different. All the parents, except one, who I interviewed for the pilot had reached a stage in therapy where their child was rarely stammering. They were reﬂecting on their experiences and not looking for guidance. However, in all the interviews I was struck by the similarities between these research conversations and the sort of conversations I might have with an adult client. I found myself using similar conversational strategies and the parents seemed to enjoy the opportunity to reflect and through talking re-think some aspects of the therapy process. The next interviews I do will be with parents currently engaged in earlier stages of therapy and I will need to be clear about the purpose of the interviews and my role as researcher. There may be tension between research and therapy in these conversations. I will need to monitor these complimentary and potentially Conﬂicting roles. It could be argued that I should not disclose my professional background but this seems dishonest. And yet if parents know I am an slt then this will inﬂuence what they chose to say. It seems likely they will not want to jeopardise their therapy in any way and although their interview is conﬁdential they may wish to present their experiences as positively as possible. In a questionnaire study Fitzpatrick (1993) found that people were reluctant to criticise healthcare experiences.
Who does the therapy?
Initial shock at being told they would do the therapy was a recurring theme. Some expressed the inconsistency in their thinking in that they know parents are the most inﬂuential people in their children’s lives and that speaking occurs primarily in the home environment but they had hoped that the slt might be able to ﬁx the stammering. It is interesting that parents are often told they ‘should get the stuttering seen to’ or something similar which also ﬂies in the face of logic and holds out the hope that there is something magical the slt can ‘do’. It will be interesting to ﬁnd out more about the process of adjustment to the parents’ role.
Some expressed difﬁculty with the transition from giving feedback on the child’s speaking in structured conversations to predominantly giving feedback in unstructured conversations. It seems there is a risk that the parent loses the sense of structure and also loses sight of what they are trying to do and how they should do it. Interestingly, slts at Lidcombe follow-up or support days have also reported a sense of losing their control of therapy at this stage. Some children make good progress initially and then plateau at the point where therapy should be in predominantly unstructured conversations perhaps reﬂecting parental and therapist difﬁculties at this stage of therapy. It will be useful to link parents experiences with changes in the child’s speaking to try and understand more about this inter-relationship.
It seems that stuttering and stuttering therapy can be difﬁcult for siblings. Mothers sometimes needed to be ingenious in ﬁnding ways to work with their child’s stuttering without siblings feeling resentful of the extra attention. Before therapy some had found the stuttering very difﬁcult to manage because of the impact of stuttering on family communication. 1 think I need to probe sibling issues in my next interviews.
Fathers were also mentioned, some wanting to be more involved while some saw the child’s stuttering and therapy as the wife’s domain. One father attended the interview with his wife and he was very clear about wanting more information on the therapy and how he would have appreciated meeting the slt with his wife early in therapy so that he could understand what was going on. The wife in this couple felt uncomfortable in the messenger role and would also have liked such a meeting. These last two points have made me more aware of issues around the integration of treatment into family life and this is particularly relevant when children’s progress is slow.
There were differences in the ways parents accounted for variations in their children’s stuttering. For example, some were very much linking stuttering with anxiety, changes within the family, new events etc. Others showed evidence of a different sort of problem solving linking the child’s speaking to the amount and type of feedback the parent was giving. The latter group had maybe intemalised a behavioural way of understanding their child. This raises the issue of compatibility between the LP and their usual way of dealing with or understanding their child’s behaviour and I need to explore ways of asking about this.
Finally, all the mothers were very welcoming and seemed to really enjoy the opportunity to reﬂect on their experiences. They were positive about their therapy and liked the idea that by sharing their views they might help take our understanding a little further. This has made me reﬂect on the possible value of occasional parent only sessions during LP to help us all take stock and reﬂect on what is going well in therapy and what needs to be addressed.
The next steps are to complete a more detailed analysis of these pilot interviews and adjust the interview guide accordingly. Then a new phase of interviewing will start and subjects selected to give as much variation as possible. At least two interviews will be conducted with each parent, the ﬁrst will be early in treatment and the second at a later stage.
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