Lidcombe Program — What's Left?

* Our good friend, Dori Lenz Holte recently published this article on her Voice Unearthed blog, and she has given us permission to share it here.

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A newly published article in the Journal of Speech, Language, and Hearing Research reported  the results of a recent study on the Lidcombe Program (Donaghy, et. al. 2020). This study divided 74 children into two groups, the control group using verbal contingencies and the experimental group removing verbal contingencies. The findings were inconclusive with outcomes being similar in both groups.

Verbal contingencies have been considered the “change agent” central to Lidcombe. I was curious as to what was left once those were removed. What was the true change agent if it wasn’t verbal contingencies? I turned to the Lidcombe Program Treatment Guide (LPTG) for a closer look. Components of Lidcombe therapy include (Onslow, et. al. 2020):

1. Parents are trained to use verbal contingencies, first in practice sessions, then in natural conversations. They are also trained to use the Lidcombe severity rating (SR) scale. Verbal contingencies include:

• Praise stutter-free speech.
• Request self-correction of stuttered speech (on a lesser basis)
• Request the child to evaluate their speech i.e., the parents asks, “was that smooth?” or “were there any bumps there?
• Acknowledge stutter-free speech with comments like, “that was smooth” or “no bumpy words.”

2. Clinic Visits:

• Parents and the clinician compare severity ratings (clinician’s severity rating is based on a clinic-based conversation with the child or a recording made during everyday life.
• Discussion of progress centered on the use and response to verbal contingencies.

The LPTG states that “Parents do not alter their customary speech pattern or speech and language habits in any way, nor do they change the family lifestyle in any way, apart from presenting verbal contingencies.” That’s not really how things play out because further on in the LPTG, parents are instructed to

• spend one-on-one time with the child once or twice a day for 10-15 minutes, ideally with a book or a game the child enjoys,
• simplify sentence structure and language complexity, and
• incorporate turn-taking.

In this study, the control group parents provide verbal contingencies during this time and the experimental group does not. They just spend time together. Playing, One-on-one. Together.

Turns out what’s left are therapy components that focus on keeping kids talking and engaged in the world around them. Sound familiar? If you know my work, you’ll know this is my mantra and I was encouraged to see this come to light although it’s not the first time.

These findings echo the findings of a study comparing RESTART-DSM (an indirect therapy) to Lidcombe (a very direct therapy (de Sonneville-Koedoot, Stolk, Rietveld, Franken, 2015). Researchers were surprised at how two very different therapies could have similar outcomes. They concluded that "the common components of 

• increased one-on-one time with parents,
• the reduction of linguistic demands, and
• an increase in emotional support

were likely to have the greatest impact." In other words, verbal contingencies are not as “active” as once thought when it comes to controlling stuttering in a child. In addition, the more recent study refers to another report in which “44% of 35 parents surveyed stated that their children displayed a negative reaction to Lidcombe verbal contingencies for stuttering” (Packman 2007 as cited in Donaghy et.al. 2020).

Lidcombe is recommended for preschoolers because this is supposedly a time when brain development and plasticity is at its peak. It’s often called “the window of opportunity” to train the brain to not stutter. While it’s true that the brain development is extremely active during these years, we must remember that this makes children even more vulnerable to planting seeds of shame and fear because the “window” has no screen. It appears that the true benefit of Lidcombe lies in environmental adjustments that can easily happen without the inherent risks of verbal contingencies. First do no harm.

References:

• de Sonneville-Koedoot, Caroline, Stolk, Elly, Rietveld, Toni, Franken, Marie-Christine, (2015). Direct versus Indirect Treatment for Preschool Children who Stutter: The RESTART Randomized Trial, PLOS ONE.
• Donaghy, Michelle, O’Brian, Sue, Onslow, Mark, Lowe, Robyn, Jones, Mark, Menzies, Ross G. (2020). Verbal Contingencies in the Lidcombe Program: A Noninferiority Trial. Journal of Speech, Language, and Hearing Research, 1-13.
• Onslow, Mark, Webber, Margaret, Harrison, Elisabeth, Arnott, Simone, Bridgman, Kate, Carey, Brenda, Sheedy, Stacey, O’Brian, Sue, MacMillan, Verity, Lloyd, Wendy (2020) The Lidcombe Program Treatment Guide.

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The American Institute for Stuttering is a leading non-profit organization whose primary mission is to provide universally affordable, state-of-the-art speech therapy to people of all ages who stutter, guidance to their families, and much-needed clinical training to speech professionals wishing to gain expertise in stuttering. Offices are located in New York, NY, Los Angeles, CA, and Atlanta, GA, and services are also available Online. Our mission extends to advancing public and scholarly understanding of this often misunderstood disorder.