About the presenter: Christine Lewis received an honours degree from Curtin University, Western Australia in 1990. On graduating she pursued her interest in stuttering, moving to Sydney to specialise in the evidence-based treatment of stuttering at what would later become the Australian Stuttering Research Centre (ASRC). In 2001 she commenced her PhD with the ASRC, at the University of Sydney under the supervision of Professor Mark Onslow & Dr Ann Packman. She recently submitted her thesis which was based on a randomised controlled trial of the telehealth model of the Lidcombe Program of Early Stuttering Intervention. .

You can post Questions/comments about the following paper to the author before October 22, 2006.

The telehealth adaptation of the Lidcombe Program of early stuttering intervention

by Christine Lewis
from Australia

It is widely accepted that stuttering needs to be treated efficaciously in the preschool years. Whilst many children who begin to stutter may recover naturally without treatment, it is not possible to identify these children from those in whom stuttering will continue into adulthood. Effective intervention within the preschool years therefore aims to prevent stuttering progressing to a chronic form.

The Lidcombe Program of early stuttering intervention is an efficacious operant treatment for preschoolers who stutter. There are resources available that explain the program in detail (eg. Onslow, Packman & Harrison, 2003), and a manual is available from the website of the Australian Stuttering Research Centre at http://www.usyd.edu.au/asrc. The safety and effectiveness of the Lidcombe Program have been demonstrated in many studies, including a randomised controlled trial that was published last year in the British Medical Journal (Jones, Onslow, Packman, et al., 2005). This trial showed that the effects of the program on stuttering are significantly greater than natural recovery.

Many Australian children and families live in rural and remote areas where there is limited contact with Speech-Language Pathologists (SLP). The barriers to services that are faced by rural and remote families include long distances to be travelled, costs associated with travelling, poor access to private transport, and inadequate public transport. As a result, many children living in these areas who start to stutter may not have access to the Lidcombe Program. Even when limited or infrequent access is possible, SLPs working with isolated families are often unable to implement all of the essential components of the program. Understandably this can result in limited effectiveness of treatment.

The Lidcombe Program is implemented by parents under the guidance of a SLP, which makes it particularly suited to a telehealth service delivery model. A coordinated research program has been investigating adapting the Lidcombe Program to telehealth delivery with the aim of providing equitable services to isolated preschool stuttering children and their families.

Telehealth has been defined as the use of information technologies and telecommunications (IT&T) to support or deliver health services to remotely located sites (Project for Rural Health Communications and Information Technologies, 1996). Telehealth aims to overcome barriers caused by distance by transferring information, rather than moving either the providers or the recipients of health-care (Craig & Patterson, 2005; McGuire, 1998; Peterson, 2000). Research into the delivery of speech-language pathology services by telehealth has emerged during the past 30 years for a range of communication and swallowing disorders, with positive and/or encouraging outcomes reported (for review, see Hill & Theodorus, 2002). This includes reports of telehealth services in the management of stuttering, such as those from Canada by Kully (2000), and Sicotte, Lehoux, Fortier-Blanc and LeBlanc (2003).

A high-tech telehealth adaptation based on videoconferencing could be considered as the preferred option in adapting the Lidcombe Program to a telehealth delivery because it allows for both audio and visual live information to be exchanged in a highly interactive context. However, the current level of infrastructure provided in rural and remote areas of Australia is inadequate to support videoconferencing. By contrast, the majority of Australian families have access to, and are able to use the telephone and email proficiently. A low-tech telehealth adaptation was therefore implemented.

The aim of telehealth Lidcombe Program is to replicate the best-practice procedures of the program as closely as possible. We therefore change as little as possible from clinic-based delivery. The adaptations and differences are:

  1. Scheduled, weekly telephone consultations between the SLP and parent replace weekly clinic visits. Additional clinical support is also provided through access to telephone and/or email contact as required. Treatment is demonstrated in training videos that show the Lidcombe Program being implemented with preschool stuttering children. The treatment is discussed in detail and adapted to the individual child and family during the telephone consultations.
  2. Measurements of the child's stuttering by percentage syllables stuttered (%SS) are made from recorded conversational speech samples sent in by the parent. These replace the baseline ratings of %SS that are made at the start of each clinic visit.
  3. Video recordings of the child are obtained whenever possible. This allows for observation of non-verbal features of stuttering.
  4. As in clinic-based delivery of the Lidcombe Program, parents record a daily severity rating (SR) based on a 10-point perceptual severity rating scale, where '1' represents no stuttering, and '10' represents extremely severe stuttering. During telehealth delivery, reliability of the parent's SR is established using recorded speech samples and/or telephone conversations between the child and the SLP that are observed by the parent.
  5. Parents record a weekly sample of treatment and send this to the SLP, who then evaluates treatment from the tape and gives feedback at the next telephone consultation. Unlike clinic-based delivery, the SLP is unable to directly observe the parent implementing treatment, which means that the components of treatment are added more cautiously and gradually. It can take up to a week before the SLP can check how treatment is going. Therefore components of treatment are added conservatively. The SLP confirms that treatment is being done safely and correctly before anything else is added. The SLP will contact the parent if there are any concerns about how treatment is going prior to the next scheduled consultation.
A series of research trials have provided replicated evidence that low-tech telehealth delivery of the Lidcombe Program is safe and efficacious, resulting in satisfactory clinical outcomes of near-zero stuttering (Harrison, Wilson & Onslow, 1999; Lewis, Packman, Onslow, Jones & Simpson, 2006; Wilson, Onslow, & Lincoln, 2004). In these studies contact between the family and the speech pathologist took place as outlined above, via telephone calls, email, and through the exchange of video and/or audiorecordings made by the parent. In the most recent study (Lewis, et al., 2006), a total of 15 children were successfully treated by telehealth, with stuttering being reduced to clinically significant levels. The results were obtained with lengthy treatment times and therefore at a high cost, which confirmed that telehealth LP is relatively inefficient when compared to traditional clinic-based delivery of the LP. However, the reduction in stuttering after 9 months of telehealth treatment was comparable to that achieved in clinic-based delivery of the Lidcombe Program. The benefits of telehealth Lidcombe Program had been maintained for between 12 and 24 months post-treatment for several children. The parents reported being highly satisfied with the outcome of treatment for their child and with the treatment process.

It is important to state that regular, clinic-based service delivery should be provided whenever this is possible. However, telehealth provides a viable, effective and acceptable option for delivering equitable services with the Lidcombe Program to isolated children with early stuttering.

Future investigations of the telehealth delivery of the Lidcombe Program are planned that will look at ways to reduce the amount of clinician time required and to investigate using videoconferencing for when this technology becomes more readily available.

References

Craig, J., & Patterson, V. (2005). Introduction to the practice of telemedicine. Journal of Telemedicine and Telecare, 11, 3-9.

Harrison, E., Wilson, L., & Onslow, M. (1999). Distance intervention for early stuttering with the Lidcombe Program. Advances in Speech-Language Pathology, 1, 31-36.

Hill, A.J., & Theodorus, D.G. (2002). Research into telehealth applications in speech- language pathology. Journal of Telemedicine and Telecare, 8, 187-196.

Jones, M., Onslow, M., Packman, A., Williams, S., Ormond, T., Schwarz, I., & Gebski, V. (2005). A randomized controlled trial of the Lidcombe Program for early stuttering intervention. British Medical Journal, 331, 659-661.

Kully, D. (2000). Telehealth in speech pathology: Applications to the treatment of stuttering. Journal of Telemedicine and Telecare, 6, 51-58.

Lewis, C., Packman, A., Onslow, M., Jones, M. & Simpson, J. (2006). A Phase II trial of Telehealth Delivery of the Lidcombe Program of Early Stuttering Intervention. Manuscript submitted for publication.

McGuire, R.A. (1998). Low-cost videoconferencing for the provision of remote stuttering intervention: Myth or reality? Retrieved 11 August, 2006 from http://www.mnsu.edu/comdis/kuster/stutter.html.

Onslow, M., Packman, A., & Harrison, E. (2003). The Lidcombe Program of early stuttering intervention: A clinician's guide. Austin, TX: Pro-Ed.

Peterson, C.L. (2000). Rural health and families: E-health solutions to health inequities. Journal of Family Studies, 6, 296-301.

Project for Rural Health Communications and Information Technologies (PRHCIT). (1996). Telehealth in rural and remote Australia. Moe, VIC, Australia: Monash University, Australian Rural Health Research Institute.

Sicotte, C., Lehoux, P., Fortier-Blanc, J., & Leblanc, Y. (2003). Feasibility and outcome evaluation of a telemedicine application in speech-language pathology. Journal of Telemedicine and Telecare, 9, 253-258.

Wilson, L., Onslow, M., & Lincoln, M. (2004). Telehealth adaptation of the Lidcombe Program of Early Stuttering Intervention: Preliminary data. American Journal of Speech-Language Pathology, 13, 81-93.

You can post Questions/comments about the above paper to the author before October 22, 2006.

September 7, 2006
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