A three-arm randomized controlled trial of Lidcombe Program and Westmead Program early stuttering interventions

Contemporary clinical conversations about stuttering: Can intervention stop early stuttering development?

PURPOSE

To discuss whether early intervention can stop stuttering development. To inform junior clinicians and students of speech-language pathology about contemporary views on this issue.

METHOD

The issue was discussed by two university researchers and two speech-language pathologists who provide public clinical services. Written conversational turns in an exchange were limited to 100 words each. When that written dialogue was concluded, each participant provided 200 words of final reflection about the issue.

RESULT

Most differences that emerged centred on the clinical evidence base for early intervention, which emphasises stuttering reduction, and how it should be interpreted.

CONCLUSION

The evidence base for early intervention has limitations and it should be interpreted cautiously. One interpretation is that reducing stuttering severity is a justifiable core of early management. Another interpretation focuses on ease of communication, anticipation of stuttering, and covert stuttering.

Lidcombe Program telehealth treatment for children 6-12 years of age: A Phase II trial

BACKGROUND

For children older than 6 years who stutter, there is a gap in clinical research. This is an issue for speech-language pathologists because the tractability of stuttering decreases and the risk of long-term psychological consequences increase with age.

PURPOSE

To report a Phase II trial of a telehealth version of the Lidcombe Program with school-age children.

METHODS

Participants were 37 children who stuttered, 6-12 years of age, from Australia, New Zealand, Hong Kong, and Singapore. Parents were trained by video telehealth how to deliver the Lidcombe Program to their child. Primary and secondary outcomes were stuttering severity and psychosocial functioning measured pre-treatment and at 6 months and 12 months after starting treatment. Parents submitted two 10-minute recordings of their child speaking in conversation, and three measures of anxiety, impact of stuttering, and communication attitude.

RESULTS

Six months after starting treatment, seven children (18.9%) attained Lidcombe Program Stage 2 criteria, 25 children (67.6%) showed a partial response to treatment, and five children (13.5%) showed no response. By 12 months, 12 children (32.4%) had reached Stage 2 criteria. Psychosocial improvements were observed 6 and 12 months after starting treatment.

CONCLUSIONS

The Lidcombe Program may eliminate or nearly eliminate stuttering for about one third of children 6-12 years of age. Randomized controlled trials with this age group involving the Lidcombe Program are warranted. In the interim, the Lidcombe Program is a clinical option clinicians can implement with this age group to reduce stuttering and its psychosocial impacts.

Treatment for Stuttering in Preschool-Age Children: A Qualitative Document Analysis of Treatment Programs

PURPOSE

The purpose of this study was to identify commonalities and differences between content components in stuttering treatment programs for preschool-age children.

METHOD

In this document analysis, a thematic analysis of the content was conducted of handbooks and manuals describing Early Childhood Stuttering Therapy, the Lidcombe Program, Mini-KIDS, Palin Parent-Child Interaction Therapy, RESTART Demands and Capacities Model Method, and the Westmead Program. First, a theoretical framework defining a content component in treatment was developed. Second, we coded and categorized the data following the procedure of reflexive thematic analysis. In addition, the first authors of the treatment documents have reviewed the findings in this study, and their feedback has been analyzed and taken into consideration.

RESULTS

Sixty-one content components within the seven themes-interaction, coping, reactions, everyday life, information, language, and speech-were identified across the treatment programs. The content component SLP providing information about the child's stuttering was identified across all treatment programs. All programs are multithematic, and no treatment program has a single focus on speech, language, or parent-child interaction. A comparison of the programs with equal treatment goals highlighted more commonalities in content components across the programs. The differences between the treatment programs were evident in both the number of content components that varied from seven to 39 and the content included in each treatment program.

CONCLUSIONS

Only one common content component was identified across programs, and the number and types of components vary widely. The role that the common content component plays in treatment effects is discussed, alongside implications for research and clinical practice.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.25457929.

The Fifth Croatia Stuttering Symposium: Part I. Treatments for early stuttering

PURPOSE

The Fifth Croatia Stuttering Symposium in 2022 continued the Fourth Croatia Stuttering Symposium 2019 theme of the connection between research and clinical practice. At the 2022 Symposium, there were 145 delegates from 21 countries. This paper documents the contents of the first of three Symposium modules.

METHODS

The module topic was that three treatments for early childhood stuttering are supported by randomized controlled trial evidence. A clinical situation was considered where a parent of a 3-year-old child asked what results to expect of stuttering treatment.

RESULTS

A distinguished scholar presented a 5-minute video interpretation of the research concerning the randomized controlled trial evidence for the three treatments. Three master clinicians then each presented a 2-minute video demonstration of how those research findings might be applied in a clinical situation. Following that, the convenors moderated a discussion between the distinguished scholar, master clinicians, and delegates regarding the research and how it applies to clinical practice.

Searching for Lidcombe Program mechanisms of action: Inter-turn speaker latency

The Lidcombe Program is a well-established and efficacious treatment for early stuttering, but little is currently known about its mechanisms of action. The present report explores the possibility that inter-turn speaker latency might be associated with such mechanisms of action. Inter-turn speaker latency was measured in audio recordings of children, parents, and clinicians conversing, taken during Lidcombe Program treatment consultations. Five clinicians reduced their inter-turn speaker latencies during clinical consultations when they were speaking to children, in comparison with when they were speaking to parents. It is possible that inter-turn speaker latency is associated with the Lidcombe Program treatment process vicariously, and this possibility requires further research.

Australian pre-service primary teachers' knowledge, attitudes, and skills regarding stuttering

Purpose: Exploring Australian pre-service primary teachers' knowledge, attitudes, and classroom strategies regarding stuttering provides speech-language pathologists (SLPs) with information that can facilitate enhanced outcomes for school-aged children who stutter.Method: In this exploratory descriptive cross-sectional study, 51 final-year Bachelor of Education (Primary) students enrolled at an Australian university completed an online survey about stuttering.Result: Responses demonstrated positive and negative beliefs. Seventy-four per cent of pre-service teachers believed that stuttering has a psychological aetiology and that students who stutter are more likely to be shy or anxious. Participants agreed that their reactions and support offered would largely be based on their assumptions rather than knowledge.Conclusion: Pre-service primary teachers share similar misconceptions and unhelpful attitudes towards stuttering with previously evaluated populations. Implications for SLPs are discussed.

Stuttering management practices in Sri Lanka: A mixed method study

PURPOSE

Speech and language therapy is a growing profession in Sri Lanka, and little is known about how stuttering is currently managed in the country. Therefore, this study aimed to investigate the current stuttering management practices in Sri Lanka and to investigate any barriers to service provision.

METHOD

A convergent mixed methods design was employed across two phases. Sixty-four Sri Lankan speech and language therapists (SALTs) participated in online surveys in phase one and ten participated in semi structured interviews in phase two. Survey data in phase one was analysed using descriptive statistics and data in phase two was analysed using thematic analysis. Results from both phases were triangulated for the overall interpretation of the data.

RESULTS

Sri Lankan SALTs conduct a comprehensive assessment, however some assessment contexts (e.g., stuttering beyond the clinic) were not routinely considered. Speech and language therapists reported using multiple and varied intervention approaches/strategies, which were often adapted and/or combined. It was noted that the delivery of treatment was more challenging. Barriers identified were including limited knowledge of some aspects of stuttering management, limited access to resources, and workplace constraints.

CONCLUSION

Overall, findings revealed that most Sri Lankan SALTs employ a comprehensive and holistic approach in assessment; however, some limited knowledge of the disorder and intervention was identified. Findings highlighted the need for further training for SALTs regarding the management of stuttering, the need for culturally and linguistically validated appropriate assessments as well as the need to consider logistical issues in clinical settings and service delivery.

Lidcombe Program translation to community clinics in Australia and England

BACKGROUND

Early intervention is essential healthcare for stuttering, and the translation of research findings to community settings is a potential roadblock to it.

AIMS

This study was designed to replicate and extend the Lidcombe Program community translation findings of O'Brian et al. (2013) but with larger participant numbers, incorporating clinicians (speech pathologists/speech anlanguage therapists) and their clients from Australia and England.

METHODS & PROCEDURES

Participants were 51 clinicians working in public and private clinics across Australia (n = 36) and England (n = 15), and 121 of their young stuttering clients and their families. Outcome measures were percentage of syllables stuttered (%SS), parent severity ratings at 9 months post-recruitment, number of clinic visits to complete Stage 1 of the Lidcombe Program, and therapist drift.

OUTCOMES & RESULTS

Community clinicians in both countries achieved similar outcomes to those from randomized controlled trials. Therapist drift emerged as an issue with community translation. Speech and language therapists in England attained outcomes 1.0%SS above the speech pathologists in Australia, although their scores were within the range attained in randomized trials.

CONCLUSIONS & IMPLICATIONS

Community clinicians from Australia and England can attain Lidcombe Program outcome benchmarks established in randomized trials. This finding is reassuring in light of the controlled conditions in clinical trials of the Lidcombe Program compared with its conduct in community practice. The long-term impact of therapist drift in community clinical practice with the Lidcombe Program has yet to be determined.

WHAT THIS PAPER ADDS

What is already known on the subject The Lidcombe Program is an efficacious early stuttering intervention. Translation to clinical communities has been studied with one Australian cohort. What this paper adds to existing knowledge A larger translation cohort is studied, comprising community clinicians and children in Australia and England. What are the potential or actual clinical implications of this work? Community clinicians from Australia and England can attain Lidcombe Program outcome benchmarks established in randomized trials. This finding is reassuring in light of the controlled conditions in clinical trials of the Lidcombe Program compared with its conduct in community practice.

Implementation fidelity in parent-implemented interventions for stuttering

Knowledge of the fidelity with which interventions are delivered in research studies is crucial to meaningful examination of intervention impact. This paper presents a review of fidelity implementation (FOI) measurements in interventions jointly delivered by speech-language pathologists (SLP) and parents in research for preschool-aged children who stutter (CWS). Four key FOI components were examined: dosage, adherence, quality, responsiveness. Thirty-six studies met the inclusion criteria for this study. Articles were published between 1990 and 2020 described nine different interventions and examined CWS aged 2-6 years. No study reported all FOI components in both the clinical and the home setting and five did not report on any FOI component in either setting. The number of FOI components reported ranged from 0 to 4 in both clinical (M = 1.5) and home (M = 1.0) settings. Across studies, dosage was most often reported (n = 27, 75.0%) and responsiveness was least often reported (n = 16, 44.4%). The number of FOI components reported in articles did not increase over time, although a trend towards greater reporting in recent years was observed. Poor reporting of FOI in intervention research presents a serious methodological concern that impacts the ability of clinicians and researchers to interpret the findings of these studies. Rigorous measurement and reporting of FOI in future intervention studies is required in order to better inform evidence-based practices for interventions with CWS.

Development and evaluation of the psychometric properties of the caregiver burden scale for parents of children who stutter (CBS-PCWS)

PURPOSE

Caring for a child who stutters can impose excessive pressure on parents. Caregiver burden affects many aspects of parents' lives. Paying attention to parents in the treatment of children who stutter (CWS) is important because parents play a key role in the treatment of CWS. The aim of the study was to develop the Caregiver Burden Scale for Parents of Children Who Stutter (CBS-PCWS) and investigate the psychometric properties of the CBS-PCWS.

METHOD

The CBS-PCWS was developed using interviews with 15 parents of CWS and a literature review. The content validity, face validity, construct validity using exploratory factor analysis (EFA), and reliability of the CBS-PCWS were investigated. The content validity was evaluated using 10 experts' opinions. Face validity was determined using interviews with 10 parents of CWS. The reliability of the CBS-PCWS was evaluated through internal consistency and test-retest reliability.

RESULTS

The scale development resulted in the creation of 137 items. During an expert panel with the presence of the research team, 51 similar items were eliminated. During the qualitative content validity stage, nine items were added to the initial scale. After determining the content and face validity, the number of CBS-PCWS items was reduced to 52 items. In the construct validity stage using EFA with responses from 364 parents, eight items of the CBS-PCWS were removed due to low factor loadings. The results of the EFA indicated that the CBS-PCWS contained five factors: psychological and emotional, personal and physical, support for caregiving, culpability, and socio-communicative. The Cronbach's alpha values of the scale domains were in the 0.78-0.94 range. In addition, the ICC test-retest coefficient for the total score of the CBS-PCWS was 0.93 and for its domains was in 0.91-0.99 range.

CONCLUSION

The CBS-PCWS has 44 items with five domains and is a valid and reliable scale that can be used for clinical or research purposes. More studies are required to evaluate further psychometric properties of the CBS-PCWS.

Systematic review of implementation quality of non-pharmacological stuttering intervention trials for children and adolescents

PURPOSE

This narrative systematic review in line with PRISMA guidelines aims to investigate the implementation quality of previously published group comparison clinical trials of stuttering interventions for children and adolescents (under age 18 years).

METHODS

We searched for publications in the databases Eric, PsychInfo, PubMed and Web of Science using the search terms 'stutt*' or 'stamm*'and 'intervention', 'trial' or 'treatment'. We reviewed the implementation elements reported in studies and how these elements were used to report intervention outcomes.

RESULTS

3,017 references published between 1974-2019 were identified. All references were screened for eligibility using predefined selection criteria resulting in 21 included studies. The implementation quality details reported varied between studies. Existing studies most commonly lacked details about the support system provided to SLPs administering the interventions and monitoring of treatment fidelity both in the clinical setting and in the home environment. Support systems for participant's parents and treatment dosage were generally well reported. Dosage was the most common implementation quality element considered in analyses of treatment effect and within discussions of findings.

CONCLUSION

Findings highlight the need for future clinical trials of stuttering interventions to closely adhere to systematic guidelines for reporting implementation quality to ensure reliability of trial outcomes. A checklist for reporting clinical trials of non-pharmacological stuttering interventions is proposed.

Conversational speech of school-age children after syllable-timed speech treatment for stuttering

Purpose: The purpose of this laboratory study was to investigate whether rhythmic speech was primarily responsible for stuttering reductions in four school-aged children after the instatement stage of the Westmead Program of syllable-timed speech (STS) intervention. The study was designed to inform further development of the program. Reduction in variability of vowel duration is a marker of STS, and it was predicted that this would be present in the children's conversational speech after Stage 1 of the program if they were using STS. To strengthen such a finding, it was also predicted that there would be no reduction in articulation rate, sentence complexity, and utterance length after treatment, as there is evidence that reductions in these can reduce stuttering. Perceptual judgments of speech quality after treatment were also made by independent listeners.Method: Participants were four children, ages 8-11 years, who completed Stage 1 of an STS program and whose stuttering had reduced significantly. Pre-treatment (PRE) and post-treatment (POST) within-clinic audio-visual recordings of conversational speech were analysed for percentage of syllables stuttered, variability of vowel duration, articulation rate, and length and complexity of utterance. Four blinded listeners made perceptual judgments of speech quality in the POST recordings.Result: Recordings of all children showed that variability of vowel duration clearly reduced from the PRE to POST speech samples. Importantly, articulation rate and language use were not compromised. Some possible indicators of rhythmicity were identified in one child in the perceptual study.Conclusion: The findings suggest that STS was primarily responsible for the clinically significant reductions in stuttering after Stage 1 of the program. There is an urgent need for more evidence-based interventions for stuttering in this age group and further development of STS interventions is warranted.

Psychological characteristics of early stuttering

PURPOSE

The purpose of this study was to use psychological measures of pre-schoolers who stutter and their parents to inform causal theory development and influence clinical practices. This was done using data from a substantive clinical cohort of children who received early stuttering treatment.

METHOD

The cohort (N = 427) comprised parents and their children who were treated with the Lidcombe Program, the Westmead Program, and the Oakville Program. The study incorporated demographic information, stuttering severity, and child and parent psychological measures prior to treatment.

RESULT

The cohort revealed nothing unusual about behavioural and emotional functioning, or the temperaments, of pre-school children that would influence treatment, be targeted during treatment, or influence causal theory development. However, a third of parents were experiencing moderate to high life stressors at the time of seeking treatment, and half the parents failed first-stage screening for Anankastic Personality Disorder.

CONCLUSION

The present results are consistent with a number of previous reports that showed that the population of pre-schoolers who stutter have no unusual psychological profiles. Hence, these results suggest that the association between mental health and stuttering later in life is a consequence of the disorder rather than being a part of its cause. The finding of the life stress of parents who seek stuttering treatment for pre-school children has potential clinical importance and warrants further investigation. Further psychological research is required about parents of pre-school children who stutter, because half the parents in the cohort failed the screener for Anankastic Personality Disorder. This is of interest because a previous study associated screening failure for another personality disorder (Impulsive Personality Disorder) with treatment dropout for early childhood stuttering.

Non-pharmacological interventions for stuttering in children six years and younger

BACKGROUND

Stuttering, or stammering as it is referred to in some countries, affects a child's ability to speak fluently. It is a common communication disorder, affecting 11% of children by four years of age. Stuttering can be characterized by sound, part word or whole word repetitions, sound prolongations, or blocking of sounds or airflow. Moments of stuttering can also be accompanied by non-verbal behaviours, including visible tension in the speaker's face, eye blinks or head nods. Stuttering can also negatively affect behavioural, social and emotional functioning.

OBJECTIVES

Primary objective To assess the immediate and long-term effects of non-pharmacological interventions for stuttering on speech outcomes, communication attitudes, quality of life and potential adverse effects in children aged six years and younger. Secondary objective To describe the relationship between intervention effects and participant characteristics (i.e. child age, IQ, severity, sex and time since stuttering onset) at pretest.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO, nine other databases and two trial registers on 16 September 2020, and Open Grey on 20 October 2020. There were no limits in regards to language, year of publication or type of publication. We also searched the reference lists of included studies and requested data on unpublished trials from authors of published studies. We handsearched conference proceedings and programmes from relevant conferences.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-RCTs that assessed non-pharmacological interventions for stuttering in young children aged six years and younger. Eligible comparators were no intervention, wait list or management as usual.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We identified four eligible RCTs, all of which compared the Lidcombe Program to a wait-list control group. In total, 151 children aged between two and six years participated in the four included studies. In the Lidcombe Program, the parent and their child visit a speech and language therapist (SLT) in a clinic. One study conducted clinic visits by telephone. In each clinic visit, parents were taught how to conduct treatment at home. Two studies took place in Australia, one in New Zealand and one in Germany. Two studies were conducted for nine months, one for 16 weeks and one for 12 weeks. The frequency of clinic visits and practice sessions at home varied within the programme. One study was partially funded by the Rotary Club, Wiesbaden, Germany; and one was funded by the National Health and Medical Research Council of Australia. One study did not report funding sources and another reported that they did not receive any funding for the trial.  All four studies reported the outcome of stuttering frequency. One study also reported on speech efficiency, defined as articulation rate. No studies reported the other predetermined outcomes of this review, namely stuttering severity; communication attitudes; emotional, cognitive or psychosocial domains; or adverse effects.  The Lidcombe Program resulted in a lower stuttering frequency percentage syllables stuttered (% SS) than a wait-list control group at post-test, 12 weeks, 16 weeks and nine months postrandomization (mean difference (MD) -2.16, 95% confidence interval (CI) -3.48 to -0.84, 4 studies, 151 participants; P = 0.001; very low-certainty evidence).  However, as the Lidcombe Program is designed to take one to two years to complete, none of the participants in these studies had finished the complete intervention programme at any of the data collection points. We assessed stuttering frequency to have a high risk of overall bias due to high risk of bias in at least one domain within three of four included studies, and to have some concern of overall bias in the fourth, due to some concern in at least one domain. We found moderate-certainty evidence from one study showing that the Lidcombe Program may increase speech efficiency in young children. Only one study reported outcomes at long-term follow-up. The long-term effect of intervention could not be summarized, as the results for most of the children in the control group were missing. However, a within-group comparison was performed between the mean % SS at randomization and the mean % SS at the time of extended follow-up, and showed a significant reduction in frequency of stuttering.  AUTHORS' CONCLUSIONS: This systematic review indicates that the Lidcombe Program may result in lower stuttering frequency and higher speech efficiency than a wait-list control group in children aged up to six years at post-test. However, these results should be interpreted with caution due to the very low and moderate certainty of the evidence and the high risk of bias identified in the included studies. Thus, there is a need for further studies from independent researchers, to evaluate the immediate and long-term effects of other non-pharmacological interventions for stuttering compared to no intervention or a wait-list control group.

Predictors of Lidcombe Program treatment dropout and outcome for early stuttering

BACKGROUND

Information is available about what predicts Lidcombe Program treatment time, but nothing is known about what predicts treatment prognosis.

AIMS

To investigate the predictors of treatment dropout and treatment outcome for children who were treated for early stuttering with the Lidcombe Program (N = 277).

METHODS & PROCEDURES

A total of 32 variables were used as predictors in regression analyses of short- and medium-term Lidcombe Program outcome, and of treatment dropout.

OUTCOMES & RESULTS

Regression analyses associated children who have better language skills and easy temperament with better treatment outcome, although only a small portion of the variance of treatment outcome was accounted for by these variables. There was an association between treatment dropout and parental scores on a personality screening tool relating to their impulsivity.

CONCLUSIONS & IMPLICATIONS

Variables identified as predictors of Lidcombe Program treatment outcome were statistically significant, but not clinically significant. They did not account for a clinically substantive portion of treatment outcomes. Findings about parental impulsivity and their relationship with intervention drop-out require replication with prospective methods and comprehensive assessment of parent psychological status. This is particularly important because parents are involved in conducting all early interventions. What this paper adds What is already known on the subject Information is available about what predicts Lidcombe Program treatment time, but nothing is known about what predicts Lidcombe Program treatment outcome. What this paper adds to existing knowledge There are predictors of Lidcombe Program treatment outcome that are statistically significant, but none are clinically significant. What are the potential or actual clinical implications of this work? Clinicians can tell parents that nothing has been found that can assist with making prognostic indications about treatment outcome for their children.

An Evaluation of an Integrated Stuttering and Parent-Administered Self-Regulation Program for Early Developmental Stuttering Disorders

Purpose This study reports findings from a clinical trial that implemented an early stuttering treatment program integrated with evidence-based parenting support (EBPS) to children who stutter (CWS) with concomitant self-regulation challenges manifested in elevated attention-deficit/hyperactivity disorder (eADHD) symptoms and compared those outcomes to CWS receiving stuttering treatment without EBPS. Method Participants were 76 preschool CWS and their parent(s). Thirty-six of these children presented with eADHD and were quasirandomized into two groups: stuttering treatment only (eADHD_standard) or stuttering treatment integrated with EBPS (eADHD_integrated). The remaining children did not meet criteria for eADHD symptoms and received stuttering treatment only (No-eADHD_standard). Pre, post, and 3-month follow-up measures of stuttering treatment outcomes as well as treatment effects on measures of child behavior difficulties and parenting practices were examined. Results Significant reduction in stuttering was found for all groups. However, the eADHD_integrated group showed a greater reduction in stuttering frequency than the eADHD_standard group, and at follow-up, stuttering frequencies in the eADHD_integrated group matched those of children in the No-eADHD_standard group, while stuttering in the eADHD_standard group remained significantly higher. Children with eADHD symptoms who received the integrated program also required significantly less stuttering intervention time than those children with eADHD symptoms who received stuttering treatment only. Families in the eADHD_integrated group reported large and significant improvements in child behavior and parenting practices. Conclusion This study provides support for an early treatment program for CWS. The integrated stuttering and self-regulation management program for CWS with eADHD symptoms proved successful for fluency and behavioral improvements, which were sustained at follow-up.