JCPSLP Vol 21 No 2 2019 DIGITAL Edition

program overly complex, and not overly difficult to learn (Goodhue et al., 2010; Hayhow, 2009). In the current study, while some parents reported not finding the treatment/s themselves complex, the actual execution of the tasks did require a steep learning curve. One participant found it challenging, having done no prior training. Typically (and especially where home practice is involved), parents should be continuously educated and trained by SLPs throughout their child’s treatment journeys, regardless of the type of communication disorder involved. Parent training is an essential component of the Lidcombe Program throughout the whole treatment process. However, when planning for concurrent treatment of stuttering and SSD, clinicians may consider the additional implementation of initial, and ongoing, parent training as part of the treatment plan to further support parents’ learning and delivery of home treatment. Goodhue et al. (2010) reported that while parents in their study found the Lidcombe Program treatment relatively easy to learn, they struggled with finding the time to implement structured practice sessions. All parents in the current study similarly commented on the demands of treating stuttering and SSD concurrently and having to implement two separate home practice sessions each day. It is therefore recommended that parents are provided with information about the time involved delivering treatment, both in the clinic and at home, before treatment commences. This would allow parents to make fully informed decisions about the best time to commence treatment, and to anticipate times when, for example, vacations, may impede its delivery. Clinicians can collaboratively and creatively solve problems with the parents so that home practice can be conducted in ways that suit their families. As previously mentioned, involving the parents in this way adheres to the arm of the E3BP model that aligns with the client’s preferences. Dollaghan (2007) reports that including clients (and/or their caregivers) in decisions related to the management of their communication disorder is highly ethical and ensures that clients are fully informed in matters relating to their care. Furthermore, the collaboration between parents and clinicians from the time of intervention planning and through the process of treatment delivery aligns with the recommended best practice “family-centred” model of service delivery, as well as the individualised nature of the provision of services under this model (McKean, Phillips, & Thompson, 2012). While some barriers to concurrent treatment were identified, facilitators were also noted. The most frequently mentioned facilitator was the structure that was embedded into the treatment process, whereby although the two communication goals were addressed concurrently, they were delivered discretely within the same session. In a commentary regarding a service delivery approach for co-occurring stuttering and SSD, Ratner (1995) put forward a framework detailing several potential options for treatment. These were: (a) serial (sequential) treatment; (b) cyclic treatment; (c) concurrent treatment with blended treatment goals; and (d) concurrent treatment with discrete treatment goals. Only the latter two options have been studied empirically (Conture et al., 1993; Unicomb et al., 2017). The parents of children enrolled in the Unicomb et al. (2017) study perceived concurrent treatment with goals delivered discretely reported this method of structured service delivery as extremely useful in minimising confusion both for themselves, and their children. Therefore, clinicians attempting to deliver concurrent treatment for stuttering and SSD within the same session can confidently aim to work on treatment goals discretely. Parents should

be encouraged to deliver their home practice for the two disorders discretely at home as well, for example, remembering not to comment on stuttering while delivering home practice for SSD, and vice versa. The treatment for both disorders delivered concurrently was noted as being both intensive and demanding by the parents involved in this study. Further, their children were quite young when undergoing treatment. These factors may result in therapeutic fatigue in both parent and/or child. Thus, motivation was regarded as important by parents. For parents, motivation came from observing their children’s success in treatment, and seeing other positive changes in their children. Therefore, when it is observed that parents using this model may be feeling less motivated and/or fatigued, clinicians could aim to directly highlight these positive aspects for the parents, to serve as a reminder of the positive changes they are seeing as a result of doing the treatment. Finally, all parents mentioned the use of tangible rewards as useful external motivators for their children during treatment activities. The use of token/tangible reward systems applied to child behaviour has a long history both generally, and as used in speech therapy (Greene & Lepper, 1974; Manning, Trutna, & Shaw, 1976). Although the Lidcombe Program uses verbal rewards (contingencies) as the primary therapeutic agent, the authors of the program note that where appropriate, these verbal contingencies may be supplemented with more tangible reward systems (Onslow et al., 2017). Where children undertaking concurrent, direct treatment for stuttering and SSD require additional motivation, clinicians may wish to consider discussing the use of tangible reward systems with the parents as needed. Limitations The participants in this study were recruited purposefully following their enrolment in earlier treatment research, which resulted in a small sample, and can therefore not be generalised to reflect the views of all parents undertaking this from of treatment/service delivery. In order to assess the true value of any treatment, it would be optimal to consider the views of all key stakeholders. Although the parents in this study did make comment on their children’s perceptions and reactions, these views did not come directly from the children themselves. Future research with aiming to holistically assess any treatment approach involving children could consider exploring the children’s own perspectives on their journey through treatment, as well as the perspectives of clinicians delivering the treatment. Finally, the participants in this study were all interviewed around 3.5 years since they originally commenced treatment in the original research trial, calling to question the currency of the parents’ reflections. However, after participating in the research trial, the children did go on to continue through Stage 2 of the Lidcombe Program. Two children subsequently experienced relapse of stuttering and were re-referred back to various services. All four children also eventually went on to receive additional treatment for SSD post-research trial. Because of the various other services involved in the continual and ongoing care of these children, the authors are unable to report the actual date of treatment cessation for all participants. No parents involved in this study mentioned having difficulties with recall of any information at any time during their interviews and this was likely due to the ongoing nature of the treatment process for all involved. Conclusion The aim of this study was to explore parents’ experiences of their involvement in their children’s treatment of two

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JCPSLP Volume 21, Number 2 2019

Journal of Clinical Practice in Speech-Language Pathology