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Journal ArticleDOI

Parent verbal contingencies during the Lidcombe Program: Observations and statistical modeling of the treatment process

01 Mar 2016-Journal of Fluency Disorders (Elsevier)-Vol. 47, pp 13-26
TL;DR: There was a positive, significant relationship between the number of verbal contingencies for stuttering provided during the first 4 weeks of treatment and time taken to complete Stage 1.
About: This article is published in Journal of Fluency Disorders.The article was published on 2016-03-01 and is currently open access. It has received 16 citations till now. The article focuses on the topics: Stuttering.

Summary (5 min read)

The Lidcombe Program

  • The Lidcombe Program is a parent-conducted, behavioral treatment developed for children aged younger than 6 years, administered with the training of a speechlanguage pathologist (SLP; Packman et al., 2015).
  • As the program is parent-conducted, parents are trained to conduct Lidcombe Program treatment during weekly clinic visits with their SLP.
  • Speech-language pathologists teach parents to apply verbal contingencies to stuttering and stutter-free speech and to measure the child’s stuttering daily in everyday situations (Packman et al., 2015).
  • These may be supplemented by non-verbal contingencies such as high-fives but non-verbal contingencies are not expected to replace the verbal contingencies.
  • Pre-treatment severity has been consistently shown to be a predictor of the time required for preschool children to complete Stage 1 (Jones, Onslow, Harrison, & Packman, 2000; Kingston, Huber, Onslow, Jones, & Packman, 2003; Koushik, Hewat, Shenker, Jones, & Onslow, 2011).

2 The current Lidcombe Program treatment guide (Packman et al., 2015) specifies a slightly different severity rating scale: 0 = no stuttering, 1 = extremely mild

  • The Lidcombe Program Treatment Guide (Packman et al., 2015) outlines five parent verbal contingencies.
  • There are three parent verbal contingencies for stutter-free speech: praise, acknowledge and request self-evaluation, and two verbal contingencies for unambiguous stuttering moments: acknowledge and request self-correction.
  • The parent typically sits with the child at a table or on the floor in a quiet place, with suitable activities such as books and games.
  • There are several randomized controlled trials in support of the Lidcombe Program (Arnott et al., 2014; de Sonneville-Koedoot, Stolk, Rietveld, & Franken, 2015; Jones et al.

Parent Delivery of the Lidcombe Program

  • To date, there has been some cursory checking of parent delivery of the Lidcombe Program for the purposes of assessing treatment fidelity but there has not been an indepth analysis.
  • That clinical trial was for telepractice and parents did not attend the clinic for instruction.
  • They reported that during practice sessions, over 97% of the verbal contingencies given were provided correctly, with the percentage of incorrectly applied contingencies ranging from 0.8–2.3% across the three mothers.
  • One mother reported providing a ratio of 1.8 contingencies for stutter-free speech for every contingency for stuttering, and she started providing contingencies during natural conversations from the first week of treatment, both of which are contrary to expectations.
  • An expanded version of the Carr Swift et al. study with more participants and more finely differentiated verbal contingency classifications would provide more detailed information about how parents are providing verbal contingencies to their children as part of the Lidcombe Program.

Participants

  • Participants were 40 children receiving the Lidcombe Program and the treating parent/guardian.
  • Thirty-eight of the parents were mothers, one was the father, and one was a grandmother who had custody of the child.
  • Twenty of the participant pairs were from Adelaide, Australia, and 20 were from Sydney, Australia.
  • In keeping with intent-to-treat principles, data collected from those participants were included in all analyses.

Treatment

  • Data collection occurred over a 32-month period.
  • Those SLPs had been practicing speech and language therapy from 2–5 years and had previous Lidcombe Program experience.
  • Apart from the previously outlined changes to terminology and the severity rating scale, the major difference between the 2008 and 2015 versions of the Lidcombe Program guide is the level of detail and problem-solving suggestions for each section of the program.
  • Two or four students were assigned to the Adelaide clinic per practicum, with each practicum running for 11–14 weeks.
  • All treating SLPs and students were aware of their involvement in the study but had no access to any of the study data nor any influence over the collection procedures described below.

Pre-Treatment Assessments

  • At a pre-treatment assessment, the SLP elicited a 10-minute clinic conversation with the child.
  • Parents were also required to document their child’s typical stuttering severity during the previous week using the same 10-point scale.
  • They were instructed to make two beyond-clinic audio recordings of their child’s speech, one conversing with a parent at home and one with an adult outside the home, that adult not being a family member.
  • These recordings were assigned %SS and a severity rating by a blinded independent SLP.
  • The average severity rating from the three Page 12 of 50 Ac ce pt ed M an us cr ip t recordings and the parent assigned typical rating was used during the accelerated failure time modeling and is presented in table 1.

Reliability

  • The two pre-treatment beyond-clinic audio recordings provided by the parent were analyzed by an independent observer blinded to the purpose of the study.
  • To calculate inter-judge agreement, the eight recordings were given to another independent observer who also calculated severity rating and %SS.
  • Inter-judge agreement was Pearson r=.92 for %SS.
  • To assess intra-judge agreement the eight recordings were provided again to the original independent observer resulting in Pearson r=.98 for %SS.

2.5.1 Treatment during practice sessions

  • Parents were given an audio recording device at the first treatment session.
  • Given the large volume of data, the first recording received each week was analyzed by one of two researchers, with 520 recordings analyzed in total.
  • Mean difference scores for each type of contingency for the two judges ranged from 0.01–1.2.
  • Intra-judge agreement was calculated by having the experimenter repeat analyses of 65 recordings (12.5%) that were randomly selected by an independent research assistant.

Treatment During Natural Conversations

  • Diary data were collected from parents on each assigned day via text message, email or telephone call.
  • Additionally hard copies of the diaries were collected at the end of the data collection period.

Analysis of Verbal Contingency Provision and Stage 1 Duration

  • Survival analysis was used in this calculation in order to include participants not completing Stage 1 (Kleinbaum & Klein, 2012).
  • Data from all participants were included until the time they dropped out of treatment or they completed Stage 1.
  • Survival analysis provides an analysis of time-to-event data.
  • These variables were tested in separate models in combination with mean pre-treatment severity rating score.

Missing Data

  • Two participant pairs had no data from the recordings of treatment during practice sessions for the first 4 weeks of treatment.
  • For these participant pairs, data from treatment during natural conversations was imputed for variables that showed a correlation with the missing variables (i.e. verbal contingencies for stuttering from the diary; both had values of zero) but not for variables that did not show a correlation (i.e. verbal contingencies for stutter-free speech from the diary).

Attrition and Clinical Progress

  • Fourteen participants (six Adelaide, eight Sydney) withdrew from the research prior to completing Stage 1 of the Lidcombe Program (35% withdrawal rate).
  • This percentage was higher than for other prospective research studies into the Lidcombe Program (e.g., 15% withdrawal rate, Rousseau, Packman, Onslow, Harrison, & Jones, 2007), but not other preschool-stuttering treatments (e.g., The Westmead Program, 52% withdrawal rate, Trajkovski et al., 2011).
  • Due to the clinic funding arrangements, withdrawing from the research also meant withdrawing from therapy.
  • So parents of children who were making slow progress might not have perceived this as problematic until a later stage of treatment when students were involved.

Number of Daily Practice Sessions

  • Parents reported that they conducted treatment during practice sessions a median of once per day with a mean of 0.8 per day (SD = 0.66, 0–4).
  • As expected, the 21 parents who supplied recordings from both the first and last 4 weeks of treatment conducted more treatment during practice sessions during the first 4 weeks of treatment (an average of once per day; mean = 1.0) than during the last 4 weeks of treatment (an average of once every two days; mean = 0.6).
  • Parent Verbal Contingencies during Practice Sessions During each practice session there was an overall mean of 18.8 (SD = 13.18, 0–90) verbal contingencies provided for stutter-free speech and an overall mean of 1.4 (SD = 1.98, 0–9) verbal contingencies provided for stuttering.
  • Most errors, 89% of them, were in the first category.
  • Percentages of children receiving verbal contingencies during natural conversations from someone other than the trained parent was consistent across the two sites (75% for Adelaide, 70% for Sydney).

Analysis of Verbal Contingency Delivery and Stage 1 Duration

  • With accelerated failure time models the estimates can be transformed into percentage changes in survival time via the exponential function.
  • Thus, for mean pretreatment severity, an increase of severity rating by one scale value was associated with a 34% increase of clinic visits to complete Stage 1.
  • The previous analysis assumes that the number of verbal contingencies for stuttering given during practice sessions is linearly related to the log of the number of clinic visits to complete Stage 1.
  • Typically the treatment involves low levels of parent verbal contingencies.

Discussion

  • The Lidcombe Program is an evidence-based early stuttering intervention that uses parent-delivered verbal response contingent stimulation for stutter-free speech and for unambiguous stuttering moments.
  • Parents deliver the treatment in the child’s everyday environment with the direction of a SLP.
  • This study investigated parent presentation of verbal contingences and modeled the treatment process duration using those verbal contingencies.

Treatment during Practice Sessions

  • The vast majority of verbal contingencies provided during practice sessions were for stutter-free speech.
  • There were 21 different types of verbal contingencies used by parents, most of which were the five in the Lidcombe Program guide or various combinations of the five.
  • Numbers of verbal contingencies for unambiguous stuttering provided during practice sessions were very low, especially relative to the much higher number of verbal contingencies for stutter-free speech during practice sessions.
  • Associations found in the statistical model suggest this may not actually be the case – the analysis instead found that more verbal contingencies for stuttering was associated with a longer time to complete stage 1 of the treatment.
  • This fits with recent findings by Donaghy et al. (2015) who conducted a randomized controlled clinical experiment comparing Lidcombe Program treatment with and without the request for self-correction contingency for unambiguous stuttering.

Parent verbal contingencies

  • The number of practice sessions relative to natural conversations decreased as would be expected across the course of treatment (Packman et al., 2015).
  • The extremely low numbers of contingencies for stuttering given as part of treatment during natural conversations suggests that verbal contingencies for stuttering may not be a necessary part of treatment, as children still achieved expected treatment gains despite these low numbers.
  • When untrained people provide contingencies the potential for adverse reactions from the child or for treatment that actively works against Lidcombe Program principles is increased.
  • It is therefore important for treating SLPs to regularly check if anyone else is giving contingencies to the child Page 25 of 50 Ac ce pt ed M an us cr ip t and to reiterate that all people providing treatment need to be trained.
  • The median number of clinic visits to complete Stage 1 was 18, regardless of whether treatment was delivered by SLPs or students.

Modeling of Parent Verbal Contingencies and Treatment Duration

  • The association between increased numbers of verbal contingencies for stuttering and increased time to complete Stage 1 was unexpected.
  • Secondly, the motor learning literature suggests that different feedback schedules support acquisition and maintenance of skills, such that feedback provision which results in a skill taking longer to learn might result in increased maintenance (Salmoni, Schmidt, & Walter, 1984).
  • It is possible that the inclusion of verbal contingencies for stuttering might slow initial treatment but increase maintenance of gains.
  • The causal relationship is unclear and as previously outlined, there are a number of possible reasons for these results.
  • Should verbal contingencies be found to not be a necessary component of the Lidcombe Program, further research investigating the importance of these factors would be indicated.

Limitations and future research

  • One limitation of the current study is the potential for the parents to have conducted treatment differently when recording themselves compared to other sessions.
  • A second limitation was the variation in numbers of recordings received from different families.
  • Of particular importance is further research into the role of verbal contingencies in the Lidcombe Program.
  • This will enable conclusions to be drawn about the importance of these treatment components to clinical outcomes.
  • The current study has shown that verbal contingencies for stuttering are associated with slowed treatment progression but it is not known what role they have, if any, in the prevention of relapse.

International Journal of Language and Communication Disorders. 38, 165–

  • A self-learning text (3rd ed), also known as Survival analysis.
  • Both the number of contingencies for stutter-free speech and the number for unambiguous stuttering were lower than expected with the ratio higher than expected.
  • C. Keep training parents to use verbal contingencies for unambiguous stuttering because they are known to improve maintenance of outcomes.

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Citations
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Journal ArticleDOI
TL;DR: Comparison of how 2 clinicians might select among therapy options for a preschool-aged child who presents with stuttering close to onset is compared.
Abstract: Purpose The purpose of the present clinical forum is to compare how 2 clinicians might select among therapy options for a preschool-aged child who presents with stuttering close to onset. Method I ...

19 citations

Journal ArticleDOI
TL;DR: The clinical challenges associated with treating pediatric clients who stutter at different stages of development are discussed and potential areas of treatment research that might serve to advance current clinical practice in the future are explored.
Abstract: Stuttering is a speech disorder, with onset often occurring in the preschool years. The prevalence of stuttering in young children is much higher than that in the general population, suggesting a high rate of recovery. However, we are unable to predict which children will recover without treatment, and it is widely acknowledged that stuttering therapy during childhood provides the best safeguard against chronic stuttering. This review reports on current evidence-based stuttering treatment options for preschoolers through to adolescents. We discuss the clinical challenges associated with treating pediatric clients who stutter at different stages of development and explore potential areas of treatment research that might serve to advance current clinical practice in the future.

15 citations

Journal ArticleDOI
TL;DR: Findings suggest that this Western program is applicable and effective with a Kuwaiti population when presented in Arabic.
Abstract: Purpose: The aim of this series of case studies was to determine (1) the impact of the Lidcombe Program on early stuttering in Arabic-speaking preschool children, (2) whether adaptations ar...

8 citations


Cites background from "Parent verbal contingencies during ..."

  • ...In a recent study by Swift et al. (2016), the correlation between contingencies provided by parents with their child during the Lidcombe Program and treatment duration were documented....

    [...]

Journal ArticleDOI
TL;DR: There was no evidence that Lidcombe Program treatment was associated with restricted language development during 18 months posttreatment commencement, and the continued search for the mechanisms underlying this successful treatment needs to focus on other domains.
Abstract: This study was driven by the need to understand the mechanisms underlying Lidcombe Program treatment efficacy. The aim of the present study was to extend existing data exploring whether stuttering ...

8 citations


Cites background from "Parent verbal contingencies during ..."

  • ...Swift et al. (2016) reported a positive correlation between verbal contingencies for stuttering during Lidcombe Program practice sessions and the number of clinic visits to complete stage 1 of treatment....

    [...]

Journal ArticleDOI
TL;DR: The inconclusive finding of noninferiority means that verbal contingencies make some contribution to the Lidcombe Program treatment effect, and an overriding impression from the trial is a similarity of outcomes between the control and experimental arms.
Abstract: Purpose The Lidcombe Program is an efficacious and effective intervention for early stuttering. The treatment is based on parent verbal response contingent stimulation procedures, which are assumed to be responsible for treatment effect. The present trial tested this assumption. Method The design was a parallel, open plan, noninferiority randomized controlled trial. In the experimental arm, the five Lidcombe Program verbal contingencies were removed from parent instruction. The primary outcome was beyond-clinic percentage syllables stuttered at 18-month follow-up. Seventy-four children and their parents were randomized to one of the two treatment arms. Results Findings of noninferiority were inconclusive for the primary outcome of stuttering severity, based on a margin of 1.0 percentage syllables stuttered. Conclusions The inconclusive finding of noninferiority means it is possible that verbal contingencies make some contribution to the Lidcombe Program treatment effect. However, considering all primary and secondary outcomes, an overriding impression from the trial is a similarity of outcomes between the control and experimental arms. The clinical applications of the trial are discussed, along with further research that is needed.

5 citations

References
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TL;DR: In this article, the Cox Proportional Hazards model and its characteristics are evaluated and the Stratified Cox Procedure for Time-Dependent Variables is extended for time-dependent variables.
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Abstract: Previous analyses of knowledge of results (KR) and motor learning have generally confounded the transient performance effects as shown when KR is present and the relatively permanent (i.e., learned) effects that we argue should be evaluated on a transfer test without KR. In this review, we classify investigations according to this distinction, and a number of new relations emerge between KR and both learning and performance. In addition to the motivational and associational roles of KR, we emphasize that it also acts as guidance, enhancing performance when it is present but degrading learning if it is given too frequently.

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TL;DR: In this article, the Cox Proportional Hazards model and its characteristics are evaluated and the Stratified Cox Procedure for Time-Dependent Variables is extended for time-dependent variables.
Abstract: Introduction to Survival Analysis.- Kaplan-Meier Survival Curves and the Log-Rank Test.- The Cox Proportional Hazards Model and Its Characteristics.- Evaluating the Proportional Hazards Assumption.- The Stratified Cox Procedure.- Extension of the Cox Proportional Hazards Model for Time-Dependent Variables.- Parametric Survival Models.- Recurrent Events Survival Analysis.- Competing Risks Survival Analysis.

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Journal ArticleDOI
22 Sep 2005-BMJ
TL;DR: Evidence is provided from a randomised controlled trial to support early intervention for stuttering in children of preschool age and the Lidcombe programme is an efficacious treatment for stuttered.
Abstract: Objectives To evaluate the efficacy of the Lidcombe programme of early stuttering intervention by comparison to a control group. Design A pragmatic, open plan, parallel group, randomised controlled trial with blinded outcome assessment. Setting Two public speech clinics in New Zealand. Participants Stuttering preschool children who presented to the speech clinics for treatment. Inclusion criteria were age 3-6 years and frequency of stuttering of at least 2% syllables stuttered. Exclusion criteria were onset of stuttering during the six months before recruitment and treatment for stuttering during the previous 12 months. 54 participants were randomised: 29 to the Lidcombe programme arm and 25 to the control arm. 12 of the participants were girls. Intervention Lidcombe programme of early stuttering intervention. Main outcome measures Frequency of stuttering was measured as the proportion of syllables stuttered, from audiotaped recordings of participants9 conversational speech outside the clinic. Parents in both arms of the trial collected speech samples in three different speaking situations before randomisation and at three, six, and nine months after randomisation. Results Analysis showed a highly significant difference (P = 0.003) at nine months after randomisation. The mean proportion of syllables stuttered at nine months after randomisation was 1.5% (SD 1.4) for the treatment arm and 3.9% (SD 3.5) for the control arm, giving an effect size of 2.3% of syllables stuttered (95% confidence interval 0.8 to 3.9). This effect size was more than double the minimum clinically worthwhile difference specified in the trial protocol. Conclusions The results provide evidence from a randomised controlled trial to support early intervention for stuttering. The Lidcombe programme is an efficacious treatment for stuttering in children of preschool age.

216 citations