Overview of the Lidcombe Program by bloved

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									Overview of the Lidcombe
Program
of Early Stuttering Intervention

  Marcia B. Kelley, M.S., CCC-SLP
            WSHA 2007
Learner Outcomes
Participants will be able to:
1.   State the treatment goals of Stage 1 &
     Stage 2 of the Lidcombe Program
2.   Describe the 2 most basic components
     of the Lidcombe Program
3.   Identify research literature/data that
     supports use of this intervention with
     preschool age children
What is Lidcombe?
a. A suburb of Sydney, Australia

b. An area with people who have low
   income, are ethnically diverse, and many
   are immigrants

c. A program to treat stuttering in preschool
   age children
What is the Lidcombe Program?
A program to treat stuttering in
 preschool age children

 Developed at the University of
 Sydney clinic in Lidcombe, Australia
Developed by researchers and
clinicians
   Dr. Mark Onslow, Elizabeth Harrison, Ann
    Packman

   Australian Stuttering Research Centre at
    the University of Sydney

   Has been in use, and continuously refined
    since conceptualization in 1980
 Still   continuously researched

 Modifications   made as evidence
  indicates

 Thousands  of children under age of 6
  years have been treated
 Is   evidence-based treatment

A     behavioral treatment

 Is   done by parents
Goals of Treatment
 Stage1
  No stuttering


 Stage  2
  No stuttering for a long period
   of time
2 Significant components
 1.Parental verbal contingencies
 given during conversation

 2.Clinical measurement of
 stuttering occurs regularly
Development of the Lidcombe
Program
 Influenced   by behavior therapy
 Isnot dependent upon the etiology or
 nature of stuttering: you don’t need to
 tease out cause of stuttering to use
 this tx
Lidcombe Program
 Treatment    aimed at speech only

 Increasing   stutter-free speech

 Decreasing    stuttering frequency &
 severity
 Is not intended to change family
  dynamics
 Is not intended to increase child’s
  awareness of his stuttering
 Is intended to make child fluent in the
  “real world”
The “puppet study”
 Martin,   Kuhl, & Haroldson (1972)
 JSHR

      experimental research directed
 First
 at decreasing child’s stuttering
 Thischallenged the diagnosogenic
 theory
     The diagnosis of stuttering itself caused
      stuttering
 Cast doubt on assumption that parent
 comments about speech caused
 stuttering
Lidcombe Program
 1990treatment evolved to essentially
 what is used today

A   verbal contingencies model

 Decidedthat parents, not clinicians,
 should provide treatment
3 fundamental concepts to consider in
developing behavioral treatment of
stuttering
 1.   Stage of Stuttering

 2.   Type of treatment

 3.   Type of instructions
Concept 1. Stage of stuttering
A. Early stuttering
     Children who stutter before age of 5
     Stuttering for a short time (often a few months)


B. Advanced stuttering
     Involves identify, self-concept, entrenched
Concept 2. Type of treatment
 A.   Simple Treatments

 Do   not teach a new speech pattern

         decreased contingent upon
 Stuttering
 consequences
B. Complex treatments
   Modify or replace stuttered speech
    pattern

   New pattern is incompatible with
    stuttering
Concept 3. Type of instructions
A. Programmed instruction
   Take steps toward treatment goal
   Criteria specified with measurement
   Performance-contingent progression
B.   Non-programmed instruction

    Treatment target is specified

    No checklist of progress steps
Details of Lidcombe Treatment
 Direct   treatment approach

 Treatment occurs in conversations in
 natural environment

 Treatment    is fun for the child
Systematic
 Main   focus is on fluency

 Bothfluency and stuttering are
 attended to

        is dependent upon careful
 Program
 measurement of stuttering
Parents are key
 Parent   is the main clinician

 Parentis trained by SLP to do the
 treatment
What do parents do?
1.   Provide verbal contingencies to
     child’s responses

2.   Measure stuttering severity
Parent Training
 Parent meets with the SLP and
 the child
  Weekly 1-hour clinic visits
  Schedule changes later
Parent Training
       training changes as treatment
 Parent
 changes

 Individualized   for each family and
 child
What training does SLP provide?
 To   recognize stuttering

 How   to measure stuttering severity

         discusses and models
 Clinician
 treatment “contingencies”
       practices contingencies &
 Parent
 measurement with child with SLP’s
 feedback

 SLP helps parent understand how to
 do structured conversations
Verbal contingencies
 Aregiven during structured and
 unstructured conversations and play

 Contingencies   are not constant or
 invasive
 Thefirst conversations in which
 parental contingencies are given are
 carefully structured by the parent

 Atthe start of program parents will
 provide the treatment only in
 structured conversations
             Treatment
     in structured conversations
         contingencies need to be
 Parental
 presented correctly

         contingencies need to be
 Parental
 presented “safely”
Child responses attended to
 Stutter-free   speech

 Unambiguous      stuttering
“Safety” factors
   More contingencies given for fluent
    speech than for stuttered speech (5:1)

   Positive reinforcement / praise / reward is
    given for fluent speech

   An occasional comment or correction of
    stuttered speech is given
Why do measurement?
   1. Confirms that progress is
  occurring
 2. Ensures that parent is using the
  Lidcombe method correctly outside
  the clinic
 3. Measurement directs treatment
Measurement guides treatment
 If progress is not happening,
  treatment must change
 If progress does happen, treatment
  must change
 Used in all clinic visits, Stages 1 and
  2
How is measurement done?
 Parentand clinician both monitor
 treatment effects

     Done every day by parent at home

     At each session with SLP in clinic
Beyond-clinic severity rating (SR)
   Is done by parent

   at home

   during daily activities

   One “global” rating given by parent for
    whole day
Severity Rating (SR) Scale
1   = no stuttering

2   = extremely mild stuttering

 10   = extremely severe stuttering
 The10 is reserved for the “most
 severe stuttering you can imagine”

 Maynot be the most severe you have
 heard the child do
Teach parent to collect SR
   Teach how and why used

   Show examples

   Stress daily use of SR
Discuss types of stutters and severity
         and quality of stuttering is
 Quantity
 considered

 E.g.,blocks are more severe than
 mild repetitions
Advantages of SR
 Sensitive to changes in stuttering
  type, even if frequency does not
  change
 Is a valuable teaching &
  communication tool
 Is perceptual
Advantages of using SR
 Makes communication more neutral
 & specific: not “good” or “bad”

 Valid
   Reacts   to variability
In-clinic measurement by SLP
   Percent syllables stuttered (%SS)

   Download the %SS counting program
    from Roger Ingham’s website:

   http://www.speech.ucsb.edu/roger.htm
%SS used by SLP at each clinic visit
   Done at beginning of clinic session
       While parent and child are conversing
       Can be while SLP & child conversing


   Tells frequency, not severity or types, of
    stutters
       all aspects are important to monitor
   Example:
   575 syllables & 38 stuttered syllables
   38 / 575 x 100 = 6.6% SS

   Practice counting with tapes
   Do one day, then redo a week later to see
    your intrajudge reliability
Treatment Process: Stage 1
 Parent  and child start with 1 hour
 clinic visits

 Everyweek (was part of research
 protocol)

 Usually   lasts average of 11-12 weeks
Teaching Treatment
 SLP  explains the Lidcombe model
 Tells parent what SLP will do
 Models the treatment
 Lets parent do it
 Gives feedback to parent
What does the parent do?
 Responds to one of the “essential
 responses:”

  1.   Stutter-free speech

  2.   Unambiguous stuttering
3 kinds of verbal contingencies for
stutter-free speech
 1.    Praise
      Vary the wording

      Be sincere

      Can be overdone
Parent verbal contingencies for stutter-
free speech
 2.   Request self-evaluation

   Parent asks child’s opinion of own speech

   Is only used for stutter-free speech

   Is also an active form of praise
Verbal contingency for stutter-free
speech
 3.   Acknowledge

 Is   a “neutral” comment

 Can be used in conjunction with
 praise
Acknowledge
 Use  when children are sensitive to
  praise
 Is a matter-of-fact statement
Examples:
 “That was smooth.”
 “You said that smoothly.”
2 Verbal contingencies for
unambiguous stuttering
1. Request self-correction
 Use   with caution
 Look for warning signs
 If in doubt, leave it out!
2 Verbal contingencies for
unambiguous stuttering
2. Acknowledge
 Isa double contingency
 Aim is assistance, not punishment
 Can be used with request for self-
  correction
Acknowledge
 Use   with caution
 Again, look for warning signs
 If in doubt, leave it out
What is a “non-essential”
response?
 Spontaneous    self-evaluation of
 speech

 Spontaneous  self-corrections of
 stuttered speech

 Not   essential to treatment
Example
 Response     to these is ALWAYS
 praise!

 “Yes,   you’re right, that was smooth.”
Be specific
      was great. You fixed that bump
 “That
 by yourself.”

 “Good one! You did a bump, and
 then you made it smooth.”
Treatment in conversations
 Structured    conversations

   Parent must structure conversations so
    child’s speech is mostly stutter-free

   Verbal contingencies given ONLY for the
    stutter-free utterances
 Usually  happens sitting down
 Is organized
 Is physically and linguistically
  constrained
    Talk about concrete, visible,
     immediate things
Typical Stage 1 clinic visit
 Parentreports SR scores for
 previous week

 SLP asks parent where and when SR
 collected

 Discuss   any difficulties or challenges
% Syllables Stuttered & SR
 Clinician   measures %SS in session

 Parent  & SLP compare SR score for
 clinical sample
Document SR
 Check     SR reliability
     use within-clinic measure (e.g., “Does
      this sound like your 6?”)
 Copy parent SRs into clinic record
 Discuss trends
     Always do this
     What kinds of stutters? When?
Purpose of Stage 1 clinic visit
 %SS  and SR scores used to look at
 clinical progress over the week

 Scores   will direct clinical process
Discuss previous week’s tx
 Cliniciangathers info regarding type
  and frequency of treatment
 Parent and clinician discuss
  treatment procedures
 Parent demonstrates treatment used
  at home previous week
SLP discusses changes for next
week
 Clinician explains changes to
  procedures for coming week
 Clinician demonstrates changes
 Clinician trains parent to do changed
  procedures
 Clinician summarizes what is
  expected for coming week
Stage 2:
 Used    to be called “maintenance”

 Is   part of treatment program itself

 Is   NOT OPTIONAL
Move into stage 2 when
 Stuttering has been maintained at
  less than 1% SS in sessions
 SR out of clinic each day 1 or 2, with
  at least four being SR1
 Criteria maintained over at least 3
  consecutive weeks
Designed to maintain low levels %SS
 Treatment  is withdrawn at home
 Frequency of clinic visits decreases
  over a period of at least one year
 Providing stuttering remains at less
  than 1% of syllables stuttered
Reasons to always do Stage 2
 Stuttering is a relapse-prone disorder
 Stage 2 designed to detect signs of
  impending relapse
 Stage 2 designed to prevent relapse
  and treat it, if occurring
Schedule of clinic visits
 All performance-contingent, but
  typically:
    2 weeks

    2 weeks

    4 weeks

    4 weeks
Clinic visits when fluency continuing
well
8  weeks
 8 weeks
 16 weeks
Length of time in Stage 2
 Set   up for 12 months

 30   minute clinic visits
 Speechmeasures collected during
 week before clinic visit

 Decrease visits according to
 preceding schedule if speech fluent
 (SR 1-2, with 2 being rare)
When Stage 2 criteria are met
 SLP reminds parent to continue
 treatment

 Some  contingencies will still given for
 stutter-free speech
Monitoring by SLP:
 Parent reports & discusses:
   what kinds of contingencies were
    given
   for what

   how often
 Parent  advised to react immediately to
 signs of relapse
   Increase or reintroduce verbal
    contingencies in unstructured
    speech
   If necessary, reinstitute use of
    structured conversations
SLP & Parent Partnership
 Parent   encouraged to telephone the
 SLP
  May just need reassurance

  Or additional clinic visits
Why is Lidcombe so successful?
 Parents continue to monitor fluency after
  treatment formally completed
 Treatment occurs in natural
  environments
 Treatment occurs by people in child’s life
       sometimes a range of people (mom, dad,
        sibling, grandparent, SLP)
Early Lidcombe outcome studies
 Onslow,  Costa, & Rue (1990)
   Preliminary report

   Treatment with 4 children

   After 9 months of tx

   Successful trend of recovery
Onslow, Andrews, & Lincoln
(1994)
 1stattempt using control group (no
  treatment), but parents opted to quit
  control & enter tx
 12 children


All not suttering 12 months post
 treatment in variety of settings
Longer term:
    Lincoln & Onslow (1997)
 Follow-up  study of 42 children
 4 to 7 years post-treatment
 Stuttering at near-zero levels
 No distinguishing features
  between typicals & children tx
  with Lidcombe
Research & Success
 High success rate with preschoolers
 Children followed longitudinally &
  remained fluent in adolescence
     Lincoln, Onslow (1997)
 Works    with children 7-12 also
     Lincoln, Onslow, Lewis, & Wilson (1996)
How long does treatment take?
 Mean  30% change in SR scores
  during 1st 4 weeks of treatment
  (Onslow, Harrison, Jones & Packman,
  2002)
 Ifthis doesn’t happen, suspect that
  Lidcombe not implemented correctly
Is it just Natural Recovery?
     2 Randomized Control Trials
1. Harris, Onslow, Packman, Harrison, &
  Menzies (2002)
    23 stuttering preschool children

    Randomized to 10 in control group

    13 in experimental group

    Pre & post measures (12 weeks)

    Treatment group improved more than 2 times
     as much (significantly more) than control
     group
2. Jones, Onslow, Packman, Williams,
  Ormond, Schwarz, & Gebski (2005)
   N = 54 (in 2 public speech clinics in N.Z.)
   Age 3-6

   All were more than 6 months post onset

   No treatment in past year
 Randomized   into 2 groups:
   %SS similar in each group

 29 Lidcombe tx for 12 weeks
 25 controls with no treatment
Highly significant results (P=0.003)
9  months after randomization /
  treatment
 Reduction of stuttering in Lidcombe-
  treated group significantly lower than
  control group
     a difference of 2.3% of syllables stuttered
      between the treatment group and the control
      group
Results
 Control  group
   decreased stuttering by 43%

   Only 15% were stuttering at minimal
    level (1.5%SS), however
   Combination of natural recovery &
    ad hoc tx
Lidcombe tx group
  Decreased   stuttering by 77%

     Lidcombe children stuttering at
  All
  minimal level
        group reduced stuttering to
 Control
 mean frequency of 3.9%SS
     natural recovery factor
 Lidcombe group reduced mean
 frequency to 1.5% SS
     Most Lidcombe kids at 9 months follow-
      up point were at Stage 2 of treatment
Linguistic complexity study
   Lattermann, Shenker, & Thordardottir
    (2005)

   Is increase in stutter-free speech
    associated with decreased linguistic
    complexity?
Results
   Found increases in MLU, percentage of
    complex sentences, and NDW (number
    different words)

   Improved stutter-free speech during
    treatment achieved without a decrease in
    linguistic complexity
WHAT NEXT?
 Download  SLP clinician’s guide and
 training manual online at:
 www.fhs.usyd.edu.au/asrc

 Jump   right in!

 Remember, this is an evidence-
 based program that really works!
                          References
   Harris, Onslow, Packman, Harrison, & Menzies (2002). An
    experimental investigation of the impact of the Lidcombe Program
    on early stuttering. Journal of Fluency Disorders, 27, 203-214.

   Jones, Onslow, Packman, Williams, Ormond, Schwarz, & Gebski
    (2005). A randomised controlled trial of the Lidcombe Program for
    early stuttering intervention. British Medical Journal, 331, 659-661.

   Lattermann, Shenker, & Thordardottir (2005). Progression of
    Language Complexity During Treatment With the Lidcombe
    Program for Early Stuttering Intervention. AJSLP, 14, 242-253.

   Lincoln, Onslow (1997). Long-term outcome of an early intervention
    for stuttering. AJSLP, 6, 51-58.
   Lincoln, Onslow, Lewis, & Wilson (1996). A clinical trial of an
    operant treatment for school-age stuttering children. AJSLP, 6, 73-
    85.

   Martin, R.R., Kuhl, P. & Haroldson, S. (1972). An experimental
    treatment with two preschool stuttering children. Journal of Speech
    and Hearing Research, 15, 743-752.

   Onslow, Harrison, Jones, & Packman (2002). Beyond-clinic speech
    measures during Lidcombe Program of early stuttering intervention.
    Acquiring Knowledge in Speech, Language, and Hearing, 4, 82-85.

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

   www.fhs.usyd.edu.au/asrc

								
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