Direct treatment for preschool age children has been shown to be effective in eliminating stuttering. Stuttering is more tractable since preschoolers have been stuttering for short periods of time, and may not have not developed negative attitudes toward speaking. Treating stuttering in school age children poses multifaceted issues for speech language pathologists. Older children have been stuttering longer and stuttering can be more complex, with the possibility of development of avoidance and speech related social anxiety. School age children have busier lives, are increasingly more influenced by their peers and may be bullied or teased. They are more able and therefore potentially more likely to manipulate conversations so that they don't stutter, causing difficulties in accurate diagnosis. As a result of these and other factors, stuttering can be less tractable in older children.

Since stuttering in school age children is considered to be more complex and multi-factorial than in preschoolers, treatments are often more complex and multi-layered. The behavioral component of treatment has traditionally included some form of speech restructuring/fluency shaping methodology. In this approach, reduced stuttering is achieved by changing some aspect of speech production, often reducing rate. Speech is then shaped to near-normal rates through programmed instruction and transferred to everyday situations. These programs provide the strongest behavioral evidence available for reducing stuttering in school age children (Boberg & Kully, 1994; Budd, Madison, Itzkowitz, Geroge & Price, 1986; Kully & Boberg, 1991; Ryan & Van Kirk Ryan, 1998; Craig et al., 1996; Hancock et al., 1998).

While published outcomes are encouraging, there are limitations that make this model impractical for some treatment settings. Therapy is based on intensive formats requiring up to 100 clinical hours. This may not be feasible for the schedule of the therapist or practical for the busy life of a school-age child. Treatment outcome may be less natural sounding and therefore less appealing to this age group. Difficulties meeting maintenance commitments can lead to relapse. For example Hancock and Craig (1998) reported about one-third of the children were stuttering in the range of 5-18% at 1 year post-treatment.

In choosing a treatment for school age children the speech pathologist should consider some key points that are necessary for successful outcomes. First, the treatment selected must be able to be completed in the number of hours available. If clinicians are restricted in the number of treatment hours they can provide, speech-restructuring programs may be less feasible. The treatment format, e.g., individual or group, weekly or bi-monthly, is another issue that must be considered before choosing a treatment. Treatments that can be adapted to service delivery models that require short term, and can be adjusted to a group format or a less intense treatment may be more realistic. One problem commonly identified by speech pathologists is the lack of generalization from in to out of clinic settings; leading to frustration on the part of clinician and child. Therefore, ease of generalization and realistic goals for treatment maintenance must also be considered. Finally, a way of measuring outcome that is easy and not time consuming is needed. Evaluating progress on a regular basis can be a motivating factor for the school age child.

Could the Lidcombe Program, a simple treatment developed for preschool age children, be successful with a school age population?

In the Lidcombe Program the clinician trains parents to administer various verbal contingencies for fluency and for unambiguous moments of stuttering, in a non-programmed manner. Standard treatment incorporates weekly visits to the clinic by the child and parent, where the clinician trains the parent to present three verbal contingencies for stutter-free speech and two verbal contingencies for unambiguous stuttering. The parent administers these contingencies in everyday conversations starting with those that are more carefully structured to maximize fluency and continuing to provide feedback in conversations throughout the day. Parents track the development of fluency using a 10-point perceptual severity rating (SR) scale where 1 = no stuttering, 2 = very mild stuttering and 10 = very severe stuttering. Stage 1 of the treatment ends when the child has achieved near-zero stuttering in everyday speaking situations over 3 consecutive weeks. Stage 2, the criterion-based maintenance then begins. The Lidcombe Program is very well described in the treatment manual (www.fhs.usyd.edu.au/asrc), a detailed clinician's guide (Onslow, Harrison & Packman, 2003) and numerous articles and book chapters.

There are currently two studies of the use of the Lidcombe Program with school age children. Lincoln, Onslow, Lewis and Wilson (1996) evaluated outcomes for 11 children from 6 years 10 months to 12 years 4 months (median age of 7 years and 8 months). Speech measures were percent of stuttered syllables (%SS) and Syllables per minute (SPM) from audiotapes of conversational speech in a series of measures taken from 2 months pre-treatment to 12 months post-treatment. A median of 12 one-hour treatment sessions was required for the participants to reduce their stuttering to below 1.5%SS on measures obtained both within and out of the clinic. At completion of a 12month performance-contingent maintenance (Stage 2), the majority of the children maintained close to zero stuttering.

Recently Koushik, Shenker and Onslow (2009) followed another group of 12 children who were between the ages of 6 years 8 months and 10 years 8 months (mean 9 years 0 months) at the start of the treatment. These children were linguistically diverse with all having been exposed to a French as a second language by age 4. Six children presented with other speech and language concerns in addition to stuttering. Speech measures were %SS and SPM collected in 3 post treatment follow-up audio-recorded telephone conversations to each child over the period of seven days. Follow-up ranged from 9-187 weeks following discharge from Stage 2 (mean 72 weeks). Parents of 10 of the children were interviewed about their satisfaction with the Lidcombe Program. Pre-treatment severity ranged from 2.7-18.9%SS and post treatment 0-1.9%SS. At follow up severity ranged from 0.2-1.7%SS. The median weeks to Stage 2 was 7.5 with a range of 6-10 weeks. Parent report was positive with seven of ten parents rating their children as SR -1 (no stuttering) or SR2 (very mild stuttering). No parent gave higher than a SR=3 to their child's speech. All parents reported that they enjoyed participating in the Lidcombe Program, even though finding time to conduct treatment in daily structured conversations sometimes was sometimes difficult due to busy home schedules.

Three children were unable to meet the criteria established for preschool age children of <1%SS and severity ratings that indicated no or very little stuttering (SR 1-2). Perhaps more realistic Stage 2 criteria for older children would be adjusted to accept some mild stuttering. Both studies found more variability in severity ratings during Stage 2 for older children than is noted in studies of preschoolers. This suggests that the schedule of Stage 2 meetings could be adjusted to reduce the frequency of clinic visits more gradually during the first 2-3 months after Stage 1 in order to support fluency maintenance during the first few months of Stage 2.

The outcomes of these studies are encouraging, suggesting that the Lidcombe Program is a viable treatment for older children, worth pursuing by the school clinician because of its' efficacy and effectiveness in treating stuttering in a short period of time. It may be that the enhanced cognitive functioning of school age children and their increased capacity to self-direct their treatment are factors responsible for the positive outcome noted.

Which school aged children would be good candidates for the Lidcombe Program? Characteristics include those who have been stuttering for shorter periods of time, have a good response to a treatment trial, e.g., stuttering can be reduced with verbal contingencies, and have had no previous operant treatment.

Some adjustments to the preschool version of the Lidcombe Program might increase positive outcome for older children. First, including the child in all decision making such as collecting severity ratings, and having a say in the type and frequency of verbal contingencies. Changing the stimulus materials to be at a higher cognitive level to interest the older child. Feedback can be more specific due to the advanced cognitive and linguistic level of this age group. Finally, as suggested previously, adjust Stage 2 criteria and schedule on a case-by-case basis to account for the greater variability noted, and for the possibility that stuttering may not be completely eliminated in this age group. For example, the current criteria for maintenance of fluency in Stage 2 is <1%SS and severity ratings of mostly '1' with an occasional '2'. When this criteria is maintained, the time between sessions is gradually extended; e.g., 2 weeks, 2 weeks, 4 weeks, 4 weeks 8 weeks. In some cases the schedule for Stage 2 for older children may have to be adjusted to decrease the frequency of clinic visits more gradually within the first two months (2 weeks, 2 weeks, 2 weeks, 3 weeks, etc.). The criteria for Stage 2 could be adjusted to accept more stuttering, for example <1.5% SS with severity rating no greater than '2'.

The Lidcombe Program application to school age children is demonstrated by this case study.

Thomas was 9 years 4 months, when first seen. As a preschooler Thomas had received an indirect treatment aimed at environmental modifications, but stuttering persisted and he received no further treatment. On assessment Thomas' stuttering was severe, with from 19-26%SS depending on the situation. Stuttering was characterized by frequent syllable and sound repetitions of up to 8 iterations per moment, and audible and inaudible prolongations lasting for periods up to 10 seconds duration. Thomas rarely speaks in class, motivating his mother to seek treatment at this time. The indications for using the Lidcombe Program included: a) no previous direct treatment, b) Thomas showed good self-monitoring/self-correction ability, c) he had a positive response to the treatment trial and d) therapy was Thomas' wanted to participate in. Thomas' mother attended and participated in all treatment sessions and conducted the treatment at home. Adjustments to the Lidcombe Program included the following:

Thomas was included in all therapy decisions and measurement and helped set all goals. In the last weeks of Stage 1 Thomas also collected Severity Ratings (SR) at school. Both mother and child compared their ratings as a point of discussion about progress and Thomas helped to set up his schedule for Stage 2.

Stimulus materials were adapted to Thomas' interests. This included anything having to do with video games, 'Where's Waldo" and other books of that nature, reading and board games.

Progress was the main reward, necessitating no tangible rewards for stutter-free speech since Thomas was highly motivated by his progress and was receiving spontaneous positive comments from his teacher. He was also able to communicate easier with his best friend.

Feedback form was negotiated with Thomas and changes in the type and frequency of feedback were made as requested by him. For example, Thomas was able to tolerate a large increase in the frequency of the verbal feedback for a short period of time to increase fluency in one difficult situation.

Manipulation of linguistic level was necessary, beginning with very structured conversations requiring shorter responses that increased fluency before moving to less structured and unstructured conversations at more complex linguistic levels.

The simple therapy was continued in spite of a problem identified when Thomas reached a plateau of SR3 and 4%S and failed to progress for several weeks. The introduction of a fluency shaping technique was proposed, but Thomas preferred increased verbal feedback provided by his mother at very specific times during the day to comment on and encourage fluency when increases in stuttering were noted. A reward based on collecting points for monitoring fluency and self-correction, was introduced as an incentive. After 3 weeks Thomas achieved an SR <2 and <2% SS and his well deserved reward. In this case, the Stage 2 criteria were adjusted to allow for some stuttering, as proposed by Thomas. Even with the adjusted criteria, severity of stuttering was mild, characterized by sound/syllable repetitions of no more than two iterations per moment with no accompanying tension or effort. This stuttering did not affect either Thomas or his listener.

Generalization and maintenance may be more difficult with an older child. Thomas assisted in this issue by collecting his own SR at school. Some brainstorms were needed to search for ways to support fluency at school. This resulted in some nonverbal feedback from his best friend and teacher for fluency only, and out-of- clinic assignments to monitor specific speaking situations and provide SR for them.

In summary, this is an example of a simple treatment for stuttering. Criterion-based rewards were used with the child's agreement only at the end of Stage 1 to increase progress. Thomas reached Stage 2 in 23 sessions over 28 weeks. Pre-treatment severity of stuttering may have been a factor in the longer treatment time to Stage 2 than has been reported in previous studies. This treatment could be easily provided within a school year. The support of Thomas' mother in providing treatment in beyond clinic settings, helped Thomas to generalize his fluency and ensured that any Stage 2 relapse would be met with a quick response.

While this example presents some positive options for working with school age children, more clinical trials are needed. Collecting data from a variety of clinical sites and evaluating diverse service delivery models of the Lidcombe Program would enhance our knowledge of the potential for this program in the 'real world'. Comparing the efficacy of the Lidcombe Program with other programs that are currently in use for this age group would increase our understanding of what works and what children may be the most suitable candidates for either program.

References

Boberg & Kully, (1994). Long-term results of an intensive treatment program for adults and adolescents who stutter. Journal of Speech and Hearing Research, 37(5), 1050-1059.

Budd, K. S., Madison, L. S., Itzkowitz, J. S., George, C. H., & Price, H. A. (1986). Parents and therapists as allies in behavioral treatment of children's stuttering." Behavior Therapy, 17(5), 538-553.

Craig, A., Hancock, K., Chang, E., McCready, C., Shepley, A., McCaul, A., et al. (1996). A controlled clinical trial for stuttering in persons aged 9 to 14 years. Journal of Speech & Hearing Research, 39(4), 808-26.

Hancock, K., Craig, A., McCready, C., McCaul, A., Costello, D., Campbell, K., et al. (1998b). Two- to six-year controlled-trial stuttering outcomes for children and adolescents. Journal of Speech Language and Hearing Research, 41(6), 1242-1252.

Hancock, K., & Craig, A., (1998a). Predictors of stuttering relapse one year following treatment for children aged 9 to 14 years. Journal of Fluency Disorders, 23(1), 31-48.

Harrison, E., Bruce, M., Shenker, R. & Koushik, S. (2010). The Lidcombe Program with School-Age Children who stutter. In Guitar, B. & McCauley, R. (Eds.). Treatment of Stuttering: Established and emerging interventions. Lippincott Williams & Wilkins,

Koushik, S., Shenker, R., & Onslow, M. (2009). Follow up of 6-10 year old stuttering children after Lidcombe Program treatment: A Phase I trial. Journal of Fluency Disorders, 34 (4), pp279-290.

Kully, D., & Boberg, E. (1991). Therapy for school-age children. Seminars in Speech and Language, 12, 291-300.

Lincoln, M., Onslow, M., Lewis, C. & Wilson, L. (1996). A clinical trial of an operant treatment for school-age stuttering children. American Journal of Speech-Language Pathology, 5, 73-85.

Onslow, M., Packman, A., & Harrison, E. (2003). The Lidcombe Program of Early Stuttering Intervention: A Clinician's Guide. Austin, TX: Pro-Ed

Ryan, B. P., & Van Kirk Ryan, B. (1995). Programmed stuttering treatment for children: Comparison of two establishment programs through transfer, maintenance, and follow-up. Journal of Speech & Hearing Research, 38(1), 61-75.

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