JCPSLP November 2017

Supporting social, emotional and mental health and well-being: Roles of speech-language pathologists

Lidcombe Program Development and validation of reflective questions Stacey Sheedy, Verity MacMillan, Sue O’Brian, and Mark Onslow

The Lidcombe Program of early stuttering intervention is an evidence-based behavioural treatment originally developed for children younger than 6 years. Problem-solving is inherent during Lidcombe Program treatment. Therefore a number of reflective questions were devised to assist speech-language pathologists (SLPs) to detect clinical procedures that vary from those recommended in the Lidcombe Program Treatment Guide and to employ suitable strategies. A two-stage validation process of the reflective questions was conducted. First, questions were developed and then revised with input from the members of the international Lidcombe Program Trainers Consortium. Then feedback on their clinical usefulness was obtained from public health SLPs. The outcomes of each stage of validation are reported and implications for speech-language pathologists delivering the Lidcombe Program discussed. T he Lidcombe Program is a behavioural treatment originally developed for young children who stutter. The Lidcombe Program Treatment Guide (Packman et al., 2016) outlines the clinical process. Parents or carers (referred to hereafter as parents) provide verbal contingencies after stutter-free speech and after moments of stuttering during conversational speech. At the beginning of the program, these contingencies are provided during practice sessions, usually implemented once and sometimes twice per day for 10–15 minutes each time. As treatment progresses the parent starts to deliver verbal contingencies during naturally occurring conversations throughout the day. The Lidcombe Program is supported by randomised clinical trials and experiments, translational research, meta-analysis and treatment process research (for an overview see Packman et al., 2016). The treatment has an odds ratio of 7.5 for children to attain below 1.0 per cent syllables stuttered at follow-up (Jones et al., 2005; Onslow, Jones, Menzies, O’Brian, Packman, & Menzies, 2012). Sustained treatment effects were shown for most children in the Jones et al. (2005) trial at a mean of 5 years post-randomisation (Jones et al., 2008). The efficacy of the treatment has been shown with three randomised trials

(Arnott, Onslow, O’Brian, Packman, Jones, & Block, 2014; Bridgman, Onslow, O’Brian, Jones, & Block, 2016; Jones et al., 2005). There are two stages of the Lidcombe Program. The aim of stage 1 is for the child to attain no stuttering or almost no stuttering. It requires the parent to deliver treatment to the child every day and to attend the clinic weekly until program criteria are met. The median treatment time for stage 1 completion is 16 weeks (Onslow, 2017). Subsequently, stage 2 commences. The aim of stage 2 is for the child to maintain no stuttering or almost no stuttering for a long and clinically significant period. During stage 2, the speech- language pathologist (SLP) guides the parent to gradually and systematically withdraw treatment while maintaining treatment gains. During stage 2, clinic visits occur less often, contingent on maintenance of treatment gains. While the procedures in the Lidcombe Program are clearly documented in the Lidcombe Program Treatment Guide (Packman et al., 2016), SLPs both within Australia and internationally have required training in the program as benchmarks were reportedly difficult to attain. Hence, the Lidcombe Program Trainers Consortium was established in 2004 to provide 2-day training workshops. There are consortium members in 11 countries across Europe, North America, Asia, New Zealand and Australia. A recent study (O’Brian et al., 2013) reported that community SLPs who had received consortium training administered the treatment more comprehensively and attained better clinical outcomes than those who did not receive that training. This raises the possibility that such training is causally related to better treatment outcomes. Clinical skill is an essential component of evidence-based practice (Sackett, Rosenburg, Gray, Haynes, & Richardson, 1996). Consequently, to assist SLPs to optimise their clinical skills with the Lidcombe Program, the Stuttering Unit at Bankstown in Sydney offers a consultation service. Two-thirds of such consultations are prompted because children do not progress through the program as expected (Harrison, Ttofari, Rousseau, & Andrews, 2003). Sources of departure from the Treatment Guide that might be responsible are well known (Harrison et al., 2003; Packman et al., 2016). Examples include: inconsistent or non-existent collection of severity ratings by parents, incorrect verbal contingencies for moments of stuttering, failure to do practice sessions daily, and sensitive children who react negatively to verbal contingencies. Clinical reasoning is built on robust knowledge and is dependent on critical thinking and reflective self-awareness (Higgs & Jones, 2008). Reflective clinical practice promotes

KEYWORDS LIDCOMBE PROGRAM PRESCHOOL REFLECTIVE QUESTIONS STUTTERING

THIS ARTICLE HAS BEEN PEER- REVIEWED

Stacey Sheedy (top) and Verity MacMillan

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JCPSLP Volume 19, Number 3 2017

www.speechpathologyaustralia.org.au