JCPSLP Vol 21 No 2 2019 DIGITAL Edition

This may relate to (but not limited to) accessibility issues (i.e., the service that provided the assessment is not able to provide treatment due to a lack of SLP expertise or limited resources as reported by SPA in 2014); dissatisfaction with the initial assessment or service; or a change of home address away from the original clinic location. Finally, this file audit also demonstrated that not all school-aged children who stutter have had previous treatment. This may impact SLP decisions in relation to treatment choice, the nature of education for the child and family, and potential responsiveness to Lidcombe Program treatment. This observation about school-aged children is of concern, given the increased likelihood of persistent stuttering in the school years, combined with possible onset of social anxiety (Donaghy & Smith, 2016). Based on the findings of this audit, it is reasonable to expect that SLPs working with this population may find it difficult to apply clinical trial evidence in practice. This is likely due to the criteria applied to determine eligible participants and hence uncertainty about how to treat paediatric stuttering cases that differ from clinical trial participants. This issue could be addressed by further education about paediatric stuttering in both undergraduate and professional contexts. Such education could include a focus on clinical translation of stuttering management for families with CALD or bilingual language status, children with concomitant disorders (as per Unicomb et al., 2017) and treatment decisions for children with mild stuttering or who present for treatment close to stuttering onset. Such education is important, as studies have previously described the frustration SLPs experience in translating scientific evidence to clinical practice both generally (Zipoli & Kennedy, 2005) and in other specific areas of practice including aphasia (Foster, Worral, Rose & O’Halloran, 2015) and speech sound disorder (Furlong, Serry, Erickson & Morris, 2018). Australian SLPs have also reported difficulties with clinical decision-making when stuttering co-occurs with other disorders (Unicomb, Hewat, Spencer, & Harrison, 2013). Limitations There are some limitations regarding the client sample. The nature of private practice generally and the specific characteristics of this sample means that participants may not be representative of all children who stutter. In particular, factors such as having sufficient financial support to afford private treatment, which would be prohibitively expensive to many families, may affect the generalisability of the findings. This file audit is also limited to the clinical practice of one SLP at one clinical site. However, it is worth noting that this is consistent with several Lidcombe Program clinical trials that also employed a single SLP at a clinical site to reduce variability (Arnott et al., 2014; Bridgman, Onslow, O’Brian, Jones, & Block, 2016; Rousseau, Packman, Onslow, Harrison, & Jones, 2007; Unicomb et al., 2017). Conclusion and future research The findings of this research highlight that while file audits were primarily designed as a quality measure under a clinical governance framework (Johnston, Crombie, Alder, Davies & Millard, 2000), they can be a useful methodology to triangulate the efficacy of knowledge translation, and more broadly to investigate treatment in a community setting. While researchers investigating stuttering treatment for children clearly need to continue to focus on

diagnoses, so this presents a challenge for SLPs (Donaghy & Smith, 2016; Unicomb et al., 2013). While, there has been some discussion over the past 10–15 years regarding the need for published research investigating treatment for this subset of the clinical population (e.g., Donaghy & Smith, 2016; Logan & LaSalle, 2003), there has been limited progress to date. Indeed, many of these client variables are reported by Van Eerdenbrugh and colleagues (2018) in their paper describing common challenges of administering the Lidcombe Program. To address this gap a small number of Lidcombe Program case studies have been published including variables such as age, language status, concomitant disorders, and service delivery (Al- Khaledi, Lincoln, McCabe, & Alshatti, 2018; Bakhtiar & Packman, 2009; Hewat, Unicomb, Dean, & Cui, 2018; Koushik, Shenker, & Onslow, 2009; O’Brian et al., 2013; O’Brian, Smith, & Onslow, 2014; Unicomb et al., 2017). Until more effectiveness studies are published, including those involving participants with co-morbidities, SLPs will need to incorporate their expertise into clinical decisions. Research will never be able to reflect every clinical scenario an SLP will face, particularly in an area like stuttering where there is such a heterogeneous population. Indeed, Sackett and colleagues’ (1996) landmark definition of evidence-based medicine specified that, while published research is important, clinicians also need to incorporate their expertise, along with consideration of their client’s values and circumstances into any clinical decision. SLPs will need to recognise that comorbidities that interrupt the speech mechanism (such as speech sound disorder), affect language function (such as specific language impairment) or impact cognition (such as intellectual disability) may, or may not, challenge the efficacy of the Lidcombe Program for their client. However, many of the other reasons why clients would not be eligible to participate in a research trial, such as onset within the last 6 months and stuttering frequency less than 1%SS, will not have any effect on the success of the treatment, as they were included to reduce the chance of recruiting children who may experience natural recovery, or indeed may not be stuttering at all. Further, this research established that over 75% of clients were preschool age. Interestingly, the parents of these children were the only group to be unaware of public service options. This could in part be explained by Reilly et al.’s (2016) finding that significantly more private than public treatment options are available for preschool SLP treatment in the state of Victoria. Further, this also substantiates their finding that 83% of preschool families requiring SLP services engage in private practice speech pathology. Given that 20% of the caseload were children under the age of 3 years, SLPs need to be educated and confident in early assessment, monitoring and education – aspects of fluency management that are not formally a component of the Lidcombe Program (Onslow et al., 2017) or the recently publish SPA clinical practice guideline (SPA, 2017). The service types that emerged in this study suggest that parents of children who stutter are not always seeking treatment specifically and may instead be seeking an assessment only. This again suggests that SLPs require explicit assessment, diagnostic, and monitoring skills, and knowledge of service pathways, including public options. Interestingly, 25% of participants had already been assessed at another service but had not returned there. Unpacking the reasons for why clients access a different service after the initial assessment would be informative.

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JCPSLP Volume 21, Number 2 2019

Journal of Clinical Practice in Speech-Language Pathology