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From: Lisa LaSalle
Date: 21 Oct 2011
Time: 11:52:52 -0500
Remote Name: 206.208.133.42
Hi Catie, You've asked a hot button question for me. A graduate student at the University of Wisconsin Eau Claire just completed a thesis on this topic with me last year (Mancuso, 2010). She cited a lot of the literature by Yairi and colleagues regarding studies that have been done with preschoolers using puppet shows, whereby one puppet stutters and the other puppet does not and the child is asked to point to which one he or she talks like. What we know from this literature is that children who stutter are often not aware of their own stuttering until about the age of four. My thesis student Jessie Mancuso was interested in whether normally fluent four-year-olds would be able to identify mild and severe stuttering in a peer who stutters, and she found that by and large they just do not comment on "stuttering" or even any differences at this age. In summary we know still very little about awareness and preschoolers. (Perhaps you would like to do some research on this topic!) It makes intuitive sense that bringing negative awareness to the behavior that we know of as stuttering may make stuttering worse in a preschooler, and that bringing neutral awareness to the difference between fluent speaking and stuttering might assist a child who stutters in learning to speak more fluently. You may already know this due to your SLP academic program(s), but in the last decade an impressive evidence base has been built up for a relatively new treatment approach known as the Lidcombe approach. The approach is named after the place in Australia where it was developed, a suburb of Sydney. Its developers are Mark Onslow and colleagues. (For further reading, you could try for example, Harrison, E. & Onslow, M.(2010) The Lidcombe Program for preschool children who stutter. In B. Guitar & R. McCauley (Eds.) Treatment of stuttering: Established and emerging interventions, Lippincott-Williams & Wilkins, pp. 118-140). The Lidcombe approach is based on operant conditioning principles, specifically response contingent stimulation, so that the parent and/or clinician, contingent on the child's fluent utterance, responds with the comment of something like, "good smooth speech." (praise). Then, contingent on a stuttered utterance, the clinician comments something like "that was a bit bumpy," and perhaps request for the utterance to be said again together smoothly (correction). A key feature of the techniques involved in this approach is a "5:1 rule" whereby five praises are delivered for smooth speech to every one bumpy correction. There is also an older, more established, so-called "Indirect" approach, whereby the child's stuttering is not referred to (e.g., Conture, 1990) and whereby adult modeling is quite important. I could cite many authors here but it is important to consider that the basis for this approach includes from the 1970s paradigms such as the Gradual increase of length and complexity of utterances (GILCU) and Extending the length of utterances (ELU) (Costello-Ingham, Ryan etc.) We know that preschoolers who stutter are much more likely to stutter when they are speaking spontaneously, in longer, more complex utterances, and that they are more likely to speak fluently when they are speaking in short, rote utterances. So in this approach the clinician can really get a lot of mileage out of that phenomenon by setting the child up to be fluent in carrier phrase-based activities. There is often good generalization at the early ages from these fluent shorter, more predictable phrases to more fluent spontaneous speech. Meanwhile, clinicians and parents can recast stuttered utterances, which is also its own form of contingency, and they can speak at slower rates, bring the dyadic rate gap down, etc. There's also an evidence base for showing that these slow, simple adult models improve the fluency of the preschoolers' speech. Finally, many clinicians counsel parents to follow their child's "awareness lead" with comments like "Everybody has trouble talking sometimes," "It's ok" etc. if their child says, even at a very young age something like "I can't say it" - "My mouth is broke" etc. When late 4- and 5-year-olds make negative awareness comments, at this stage the child has often been stuttering for more than a year or two. Length of time since onset and response to Tx considerations are just another part of the "art and science" of effective therapy at the preschool age ranges - how long the chlid has been stuttering and all the other risk factors, worth paying attention to such as family history of stuttering, etc. (e.g., Yairi & Ambrose, 2005). My own bias about these two approaches (Direct, or Lidcombe-like vs. Indirect, or GILCU-ELU+modeling-based) is that why not combine them? Sometimes children will do very well in terms of their overall recovery after less than one year of therapy with the indirect approach alone (e.g., see data provided by Richels and Conture 2010 in the same Edited Guitar & McCauley book). But other times preschool children plateau in their progress (perhaps due to higher risk factors to persist) in the Indirect-alone approach and then it makes sense to introduce the concepts of smooth and bumpy, be sure that the child can auditorily discriminate between the two, and then begin the 5 to 1 verbal contingencies as Lidcombe-like augmentation. I just began teaching and supervising at a new-to-me university clinic where I have a caseload of six boys - late 5-year-old and early 6-year-old boys who stutter. They all had fairly pure Lidcombe approach therapy backgrounds. So each boy is aware that speech (my/yours/ours?) is sometimes smooth and sometimes bumpy. Interesting to note that they're all currently at what I would call a "residual stuttering level." With one exception of a boy who's at a more moderate level of severity (his father stutters), the five boys each average 2-7 stutters per 100 words of spontaneous excited basline levels of talking, with not too many advanced types (Audible sound prolongations and blocks). But talk about awareness! They've got it. One boy reportedly said to his mom last week, "How many more days until we go to the class where we don't talk bumpy?" She framed this in a positive light. As a clinical supervisor, I frame it positively as she does, but an interesting question about all this awareness at late 5 and 6 is what do we now do with it? All of the boys will apparently allow A LITTLE BIT of clinical talking about about smooth and bumpy speech here and at home, but most boys have shown us in their verbal and nonverbal behaviors that they don't want to talk about it TOO much. Make sense, because, think about it, they're mostly smooth now, and deserve to be treated as just 6-yr-old conversationalists who only occasionally speak bumpy. (And want to be heard for WHAT they are saying, not only HOW they are saying it). A couple boys are negatively aware of even the smooth praise - e.g., ignore the clinician or parents reportedly said they "don't like to talk about their speech" anymore. I encountered this at my previous university clinic. Anyway, loooong answer, Catie, but again, it's a really hotbutton question for me right now, as the Lidcombe approach is relatively new to our field of practice. I wonder why we would want to throw the good ol' effective Indirect Childhood Stuttering Tx methods out. Frankly, I also can't help wonder if these boys would be fully recovered by now if Indirect GILCU+modeling methods had been included as an augmentation to the "direct or awareness-based method" belonging to the Lidcombe approach. Replacing early negative awareness with neutral and positive awareness seems to be a good thing, and these boys are much more fluent than they were at one time, no doubt, based on records and parent reports. We need more treatment efficacy studies in this area of Direct (awareness-based or Lidcombe-only, Lidcombe-based) vs. Indirect approaches with 3- to 5-year-old children who both stutter and who show risk factors for persisting in stuttering (another area of research for you to pursue :)