The Lidcombe Program From: Amy Date: 10/4/99 Time: 4:11:17 PM Remote Name: 205.188.198.37 Comments Has any one component of the Lidcombe Program been given credit for its success? Have there been any studies done to determine if, for example, the parental involvement and training is in part responsible for its success or were any of the other components considered more vital to it's success? Also, is this program only successful for children up to a certain age? If so, why is that the case? Re: The Lidcombe Program From: Michelle Lincoln Date: 10/10/99 Time: 8:50:25 AM Remote Name: 129.78.64.2 Comments Hi Amy Thank you for your questions. Colleagues of mine Elisabeth Harrison and Mark Onlsow are investigating the contribution that the correction component and parental speech measures make to the outcome of the program. They have not published their results yet so at this stage all we can say is that the treatment when administered in its entirity yields the types of results you will find in the papers. We have published an efficacy study that included subjects up to 12 years of age so the efficacy is unknown beyond 12. I suspect it may work with some adolescents and adults but it remains to be tested. Michelle on-line feedback from parents - positive and negative From: Caroline Bowen / cbowen@tig.com.au Date: 10/4/99 Time: 11:16:01 PM Remote Name: 206.17.105.2 Comments Hello Michelle! Re: "Also of interest are the reports by parents that they continued to provide on-line feedback in the long-term. Perhaps this suggests that for some children control of stuttering continued to be reliant on parents’ feedback." Yes, that really IS interesting, and I wondered if you could define "feedback" in this particular context in greater detail. I am interested to know: (1) Whether feedback includes not only the "that was a bumpy one" type of parent-feedback, commenting on dysfluencies, but ALSO, the "no bumps that time" type, in response to the child's fluent speech output.(2) Whether you have data on the breakdown / ratio between these two. In my clinical experience, adults often comment more readily on what children are doing wrong, finding it quite difficult to remember to praise (fluent speech and other "desirable" behavior). (3) Whether you actively encourage the skills of self-reinforcement in children (as in, "Give yourself a pat on the back for being a smooth talker"), and if so, (4) whether you train parents and caregivers to administer this aspect of therapy? Best wishes: Caroline Re: on-line feedback from parents - positive and negative From: Michelle Lincoln Date: 10/10/99 Time: 8:44:47 AM Remote Name: 129.78.64.2 Comments HI Caroline, Thanks for your questions! I'll answer them using the numbers that you have indicated. 1. the parents responses indicated that they continued to praise and correct children's speech in the long-term but it may have been as infrequent as as once or twice per month and for others it may have been once a week. 2. no I haven't ever reserached the ratio of praise to correction used by parents this would be really interesting particularly outside of the clinic. When training parents we ensure that on tapes from home they are using the ratio that has been agreed on between the clinician and parent. I agree adults do tend to focus more on the negative than the positive and this is often a focus of the parent training, it also the reason why the treatment needs t to be carefully monitored by a speech pathologist 3. Yes we do encourage children to recognise and comment on their stutter free speech, they will say things like "that was good talking wasn't it mum". 4. If the child shows evidence of emerging self-monitoring skills them we encourage this and train parents to comment on this at home. I hope this addresses all your questions Regards Michelle Re: on-line feedback from parents - positive and negative From: Caroline BowenÊÊÊÊÊÊ ( cbowen@tig.com.au ) Date: 10/19/99 Time: 5:30:17 AM Remote Name: 206.17.104.186 Comments Thanks Michelle - that's great! Current therapy in schools From: Lynn May mayml@hotmail.com Date: 10/5/99 Time: 10:58:13 AM Remote Name: 150.216.146.11 Comments Michelle Lincoln- I found your article very interesting. I am interested in knowing about the current therapy available in the Australian public school system. Also, how do you plan to develop a treatment package for rural areas? Thank you for your time. PS - I have relatives living in Wee Waa, NSW. Have you ever heard of this town? Re: Current therapy in schools From: Michelle Lincoln Date: 10/10/99 Time: 8:44:28 AM Remote Name: 129.78.64.2 Comments Hi Lyn In NSW the Australian state that I live in, speech pathologists are not employed by the education department to work in schools. So school-age children who stutter generally attend community health centres out of school hours with their parents to get treatment for stuttering. We feel that direct, consistent parental involvement in the treatment is important to it's success. My colleague Linda Wilson is currently evaluating the efficacy of a distance intervention package for the Lidcombe Program. If the results are positive I'm sure the package will be made available. Yes I think I've been to Weewaa! Regards Michelle feedback From: Salena Date: 10/7/99 Time: 10:52:26 PM Remote Name: 209.181.170.193 Comments Hi, interesting article. I had some of the same questions Caroline Bowen asked like defining the feedback; good and bad, etc? Also,I realize this is an approach for children but has anyone attempted to modify it for older adolescence or adults? Re: feedback From: Michelle Lincoln Date: 10/10/99 Time: 8:44:09 AM Remote Name: 129.78.64.2 Comments Selena re defining the feedback, my current research is focused on describing exactly what parents and clinicians do when they correct the stuttered speech of preschool children. I'm using conversational repair analysis as the framework for doing this, it is too early to discuss the results. When teaching about the Lidcombe Program I describe positive feedback as comments about stutter free speech that the child enjoys and interprets as reinforcing e.g great talking , you said that smoothly, wow no bumps etc. Negative feed back comments on stuttered speech, it should not be punitive but rather supportive e.g that was a bumpy word, try it again, can you say xx again. It is likely that the Lidcombe Program would be effective with some adolescent and possibly some adults but we currently \ do not have any efficacy data about this. Michelle Your Efficacy Studies From: Darrell Dodge Date: 10/8/99 Time: 3:09:43 AM Remote Name: 152.205.215.76 Comments Hi Michelle: Seems you are planning to do a great deal of development work on this program. Before you do that, however, you may want to look at the fluency outcome for children whose parents did not volunteer followup results, since the understanding of "failures" would seem to be critical to improving your approach. It is not really made clear in the discussion of your efficacy studies that only children whose parents volunteered follow-up results were included. This group of children contained -- in at least one study I recall -- only one stutterer who could be characterized as severe. Given the fact that this program virtually requires that parents become responsible partners in the therapy process, wouldn't it be logical to think that parents whose children didn't do very well with this type of "intervention" might be more reluctant to participate in the follow-up? Given the obvious answer to that question, how do you justify the global efficacy claims for your program? And what do you do about healing those parents of children who "failed," and who now may go through life wrongly blaming themselves even more for their child's stuttering? It seems to me that there is a built-in "confound" to any efficacy studies for the Lidcombe program. Parents of children who are responding well would naturally have more "buy-in" to the program than parents of children who were having more difficulty. Because this is a more emotional and personal situation (rather than a professional, therapist relationship with the child), the possible failure of parents to "buy-in" because their children are not progressing should be a key issue. The danger is that the children who need the most direct help may end up receiving the least. I think your program contains some very valuable approaches for dealing with the exacerbation of stuttering by parents whose concern places extra stress on their children. The concept of counseling parents is a good one; however, it tends to take away the opportunity for the SLP to work directly with the child, given the burden of expense and time. That is why efficacy studies for this program are critically important. And it is also why the present state of yours should raise serious concerns. Regards, - Darrell Dodge, USA Re: Your Efficacy Studies From: Michelle Lincoln Date: 10/10/99 Time: 8:43:45 AM Remote Name: 129.78.64.2 Comments Dear Darrell Thank you for your comments on the Lidcombe Program and our efficacy research. You have raised several concerns about the methodology of the studies and these seem to centre around the inclusion of subjects who volunteered to participate in the study and the likelihood that these were successful cases. I agree that this is likely to be the case in Lincoln and Onslow 1997, the long-term follow-up study. Indeed the criteria for inclusion in the study was that they had been successfully treated at approx 12 months posttreatment, we then followed them up 2 to 7 years posttreatment. Your comment that only the results for children whose parents volunteered to particpate in the research is difficult to follow given that it would be unethical to include subjects whose parents have not given consent. The issues around the sampling bias in this study you will find are extensively addressed in the discussion of the paper and consequently we make no global claims simply that the 43 children who were followed up were stutter free 2-7 years posttreatment. With regards to including only successful cases in our other efficacy studies, subjects were recruited pretreatment so we could collect pretreatment data, consequently we had no way of knowing which were likely to successful and which unsuccessful. You have also expressed concerns about "failures" and I agree that all research should report drop out rates from treatment and you will find that our studies do just that. However, do not confuse dropping out from a research project with dropping out from treatment. The majority of the drop out from our studies did so because they could not complete the rigorous data collection procedures associated with the research protocol not the treatment. For example 9 of the 22 children recruited in Lincoln, Onslow, Lewis and Wilson 1997 dropped out because they did not complete the pretreatment tape recordings and therefore were eliminated from the research before they started the treatment. These children were subsequently treated in the normal manner. My experience is that parents and children (who are not involved in research) drop out of treatment because of circumstances occuring in their life e.g.illness, marriage break up. In these cases we help the parents to make a decision to discontinue for a while until things have stabilised In our experience these people usually return to the clinic at a later stage to pursue further treatment. This suggests to us that these people do not see themselves as "failures" or to blame for the child's stuttering rather that it isn't the right time in their life to be seeking treatment. You mentioned the spread of severity of stuttering in our subjects. The range of severity of stuttering is not distributed on the normal curve in the stuttering population. There are far more cases of mild and moderate stuttering that severe ones and consequently our sample was selected to reflect this distribution. I don't believe we have made global efficacy claims. The treatment was effective for the cases we have \ reported in the literature, we have reported drop out rates and discussed sampling bias and we have provided %SS measures gathered in different speaking situations over a long-period of time. Our claims are restricted to what these data demonstrate. It seems from your final paragraph that you have confused parent training with parent counselling. The Lidcombe Program consists of clinician and parent intervening directly with the child's speech. Consequently those chidlren who benefit from direct clinician intervention receive this along with parent administered treatment. Those who need the most direct help receive it in fact all children receive direct help. Finally, you have commented on the serious concerns about the present state of the efficacy research of the Lidcombe Program. Currently our program is the only intervention for preschool children to produce published peer reviewed, reliable long and short term data on the efficacy of our program. I think a more appropriate statement is that serious concerns should be expressed about all the other treatments for preschool children that are used that have failed to produce any efficacy data. I concede that we have many more aspects of the program that need to be researched and some of these have been highlighted in my paper but I guess at least we are doing it and publishing so it can be scrutinised by people such as yourself. Michelle Re: Your Efficacy Studies From: Darrell Dodge Date: 10/12/99 Time: 12:15:24 AM Remote Name: 171.208.184.20 Comments Hi Michelle: Thank you for your detailed response to my questions. I’ve already read similar responses by your program in several journal articles and I continue to be impressed by your insistence that any failures of your approach to totally eradicate stuttering in the preschool population must be due to situational problems experienced by the parents. I continue to wonder whether some of the 65% of the “successful” children whose parents didn’t fully participate in the efficacy study may have experienced a relapse – a possibility you raise yourself in your 1997 paper, but don't develop. I think there’s much to be learned from failures, and a lot your program would gain from seriously considering that possibility, rather than totally attributing “drop-outs” to parental life situations. Of course, I'm willing to believe that in this population, and due to the major involvement of parents, treatment failures may be more difficult to find or document. You suggest that I have “confused” participation in a treatment program with participation in a research study. Many of the key issues are the same, however, and I doubt that parents make the sort of distinctions that we do. From the parents’ viewpoint, this activity is really only a part of “raising a child,” and your program places a lot of the burden for their child’s fluency on them. (This is different than the situation faced by a therapist, who is trained to avoid close identification with the child.) It is inevitable that parents whose children are “successful” (fluent by your standards) would be more likely to respond to a request to make three audiotapes and send them in for analysis than those with continuing and returning dysfluencies. In order to complete a program like this—requiring a long-term behavior change and continual vigilance over a period of a year or more—I would think that all the “successful” parents would have to be extremely conscientious and committed. Is it possible that making three 10-minute audiotapes was very difficult for them, as you suggest? Again, I defer to your experience here. In going back over your 1997 research article, which I hadn’t read in many months I'm afraid, I noticed once again the practice of basing all of your follow-up %SS results on audiotapes (not even videotapes) of children collected by their parents, rather than having at least some direct re-evaluation by trained SLPs. A program that rewards fluency rather than modification needs to make absolutely sure that the subjects involved are not using avoidance techniques or word substitutions to maintain high fluency scores, and that speech samples are random and representative within the speaking situations specified. It is a problem that none of the samples required reading from a standard text (or responding to a standard question set), which would help identify avoidance by some children and withholding of dysfluent samples by the parents. I would think these questions were raised by your peer reviewers, together with the possibility of confusing fluent-sounding speech with lack of stuttering. This is one area on which I can't defer. Finally, I’d like to focus on a passage in your article here that serves to illustrate the reason for some of my questions: “Taken together the results of these three studies suggest that the Lidcombe Programme is effective in reducing stuttering to near zero levels in the short and the long-term. This result was achieved for all the subjects who completed the program and were available for follow-up in the long-term.” If this is not a global-sounding statement, I don’t know what is. The clear implication for an uninitiated person reading this “sound-bite” is that all one has to do is “get through” this course of treatment to achieve “near-zero” levels of stuttering. I have actually seen people interpret these statements in this way and they generate a lot of the interest in your program. In fact, what is not mentioned is what “completion” of the program means and what being “available” for follow-up means. I understand that “completion” of the program is actually achieved when fluent speech is attained to your standards. The use of the word “available” is inaccurate from the point of view of the former client-parents, who may well have been available but did not choose to participate. Therefore it is more accurate to say: “The Lidcombe Programme is effective in reducing stuttering to near zero levels in the short and long term. This result was achieved for all the subjects who achieved fluent speech under the program and who participated in long-term follow-up studies.” I think that anyone reading and thinking about this more accurate statement would have some of the same questions that I do. I agree that it’s unfortunate we don’t have long term efficacy data for other treatment approaches. However, while I understand you are doing your best with what you have and within a limited research objective, your program does tend to ignore confounds that would be problematic for others. I suspect this is part of the reason for the somewhat hostile reception your work receives in many quarters. I continue to think that the concept of counseling or training (as you say) the parents of children who stutter more extensively than is now done is a very worthwhile contribution of your program -- even for other treatment approaches. Your results are impressive – even for this population. I don’t necessarily agree with what you train parents to do (or agree that this is really “direct” therapy), but I applaud the general concept. Regards, - Darrell Dodge Re: Your Efficacy Studies (Retry - Quotes repaired) From: Darrell Dodge Date: 10/12/99 Time: 2:41:35 AM Remote Name: 152.170.56.58 Comments [quotations and dashes repaired] Thank you for your detailed response to my questions. I've already read similar responses by your program in several journal articles and I continue to be impressed by your insistence that any failures of your approach to totally eradicate stuttering in the preschool population must be due to situational problems experienced by the parents. I continue to wonder whether some of the 65% of the "successful" children whose parents didn't fully participate in the efficacy study may have experienced a relapse -- a possibility you raise yourself in your 1997 paper, but don't develop. I think there's much to be learned from failures, and a lot your program would gain from seriously considering that possibility, rather than totally attributing "drop-outs" to parental life situations. Of course, I'm willing to believe that in this population, and due to the major involvement of parents, treatment failures may be more difficult to find or document. You suggest that I have "confused" participation in a treatment program with participation in a research study. Many of the key issues are the same, however, and I doubt that parents make the sort of distinctions that we do. From the parents' viewpoint, this activity is really only a part of "raising a child" and your program places a lot of the burden for their child's fluency on them. (This is different than the situation faced by a therapist, who is trained to avoid close identification with the child.) It is inevitable that parents whose children are "successful" (fluent by your standards) would be more likely to respond to a request to make three audiotapes and send them in for analysis than those with continuing and returning dysfluencies. In order to complete a program like this -- requiring a long-term behavior change and continual vigilance over a period of a year or more -- I would think that all the "successful" parents would have to be extremely conscientious and committed. Is it possible that making three 10-minute audiotapes was very difficult for them, as you suggest? Again, I defer to your experience here. In going back over your 1997 research article, which I hadn't read in many months I'm afraid, I noticed once again the practice of basing all of your follow-up %SS results on audiotapes (not even videotapes) of children collected by their parents, rather than having at least some direct re-evaluation by trained SLPs. A program that rewards fluency rather than modification needs to make absolutely sure that the subjects involved are not using avoidance techniques or word substitutions to maintain high fluency scores, and that speech samples are random and representative within the speaking situations specified. It is a problem that none of the samples required reading from a standard text (or responding to a standard question set), which would help identify avoidance by some children and withholding of dysfluent samples by the parents. I would think these questions were raised by your peer reviewers, together with the possibility of confusing fluent-sounding speech with lack of stuttering. This is one area on which I can't defer. Finally, I'd like to focus on a passage in your article here that serves to illustrate the reason for some of my questions: "Taken together the results of these three studies suggest that the Lidcombe Programme is effective in reducing stuttering to near zero levels in the short and the long-term. This result was achieved for all the subjects who completed the program and were available for follow-up in the long-term." If this is not a global-sounding statement, I don't know what is. The clear implication for an uninitiated person reading this “sound-bite -- is that all one has to do is "get through" this course of treatment to achieve "near-zero" levels of stuttering. I have actually seen people interpret these statements in this way and they generate a lot of the interest in your program. In fact, what is not mentioned is what "completion" of the program means and what being "available" for follow-up means. I understand that "completion" of the program is actually achieved when fluent speech is attained to your standards. The use of the word "available" is inaccurate from the point of view of the former client-parents, who may well have been available but did not choose to participate. Therefore it is more accurate to say: "The Lidcombe Programme is effective in reducing stuttering to near zero levels in the short and long term. This result was achieved for all the subjects who achieved fluent speech under the program and who participated in long-term follow-up studies." I think that anyone reading and thinking about this more accurate statement would have some of the same questions that I do. I agree that it's unfortunate we don't have long term efficacy data for other treatment approaches. However, while I understand you are doing your best with what you have and within a limited research objective, your program does tend to ignore confounds that would be problematic for others. I suspect this is part of the reason for the somewhat hostile reception your work receives in many quarters. I continue to think that the concept of counseling or training (as you say) the parents of children who stutter more extensively than is now done is a very worthwhile contribution of your program -- even for other treatment approaches. Your results are impressive – even for this population. I don't necessarily agree with what you train parents to do (or agree that this is really "direct" therapy), but I applaud the general concept. Regards, - Darrell Dodge Re: Your Efficacy Studies (Retry - Quotes repaired) From: some final thoughts Date: 10/17/99 Time: 11:26:01 PM Remote Name: 129.78.64.2 Comments Dear Darrell, Yes I agree there is a lot to be learned from "failures" and it is true that these people are the most difficult group to access for follow-up in the short and long-term, perhaps if you have a solution to this problem you might let me know. Your comments re the type of speech samples collected reflect a comon dilemna that researchers face i.e collecting as close to naturalistic samples as possible or standard contrived samples.(Our subjects were too young to read but may have responded to standard questions). Given that these were very young children we decided to collect as natural as possible samples: talking in their homes with parents, friends and covert recordings. This did mean that we had to rely heavily on the good will of the parents to collect the tapes, the presence of a researcher would have reduced the "normalcy" of the interaction and consequently the validity of the results. Finally "completion" refers to completing the maintenance phase of the treatment and "available for follow-up" means those subjects whose parents agreed to participate in the study. Perhaps you might also have some suggestions for how to collect the tapes we required from subjects year after year, when they were not paid and for the most part were no longer concerned about stuttering, perhaps you could try it yourself! Michelle Re: Your Efficacy Studies (Retry - Quotes repaired) From: Darrell Dodge Date: 10/22/99 Time: 2:55:10 PM Remote Name: 152.172.254.42 Comments Hi Michelle: One way of increasing follow-up responses would be to decrease the importance of superficial (albeit necessary) fluency measures (like %SS) in your program. You keep projecting the impression that your program is 100% successful, and I think that's probably a reflection of something systemic in your approach, which would definitely be picked up by parents. I really think that "researchers" (who are actually "people" capable of getting down on the carpet and playing with children, I presume) can acquire naturalistic samples of children's speech. There is nothing like the "up-close-and-personal" approach. I don't see how this would be an "abnormal" situation, given the fact that they will soon be going off to school to interact with teachers and other adults. I do see how it would be more of a challenge for the children to be fluent in this situation and that their performance would indicate if the fluency had transferred out of the household. Isn't that what you want to find out? I would love to accept your challenge and design a more believable efficacy program. I've suggested some things that would help. Maybe they will help someone. And maybe I'll be able to act on my interest in research some day. In reading back over this thread (and even over this letter) I find I must really apologize to you for the caustic nature of some of my remarks, which are partly motivated by my own experience as a person who stutters. Believe me when I say that I do appreciate the contributions your program has made and your patience in responding to me. - Darrell Dodge interested in knowing more From: Laurie In Minnesota Date: 10/11/99 Time: 11:19:15 AM Remote Name: 209.18.242.35 Comments Thank you for your information on the Lidcombe Program. I plan to check out the web site you listed. I would like to get more information in the future about the results of the program. Re: interested in knowing more From: Michelle Lincoln Date: 10/17/99 Time: 11:05:26 PM Remote Name: 129.78.64.2 Comments Dear Laurie We will continue to publish our results in internaional peer reviewed journals as they evolve! Michelle Help From: Suzanne Danforth, USA Date: 10/22/99 Time: 9:09:06 AM Remote Name: 24.218.91.126 Comments Dear Michelle, the web site address you gave in your paper is not working for me....I'm very interested in following-up with the details of the program. Thanks, Suzanne Re: Help From: Judy Date: 10/22/99 Time: 5:11:50 PM Remote Name: 134.29.30.79 Comments Thanks for noticing, Suzanne. The URL in the paper is now correct. Judy