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I am working in a clinic where no-one else is trained in the Lidcombe Program. I have only worked with three clients so far and I am not sure how quickly I should be expecting any change in their stuttering and their Severity Ratings. Is there anything written about this that I could read?

There are many publications that are useful in informing expectations. In summary, they all suggest that you should see a downward trend in severity.
Onslow et al. (2002) found that there was a 30% decrease in average weekly severity ratings from clinic visit 1 to 5.

Jones et al (2000) did a large-scale file audit and reported that there was a median of 11 clinic visits to reach Stage 2 and 90% reached Stage 2 in 22 visits. Note that this was prior to the recommendation in the Lidcombe Program Guide that criteria should be met on three consecutive clinic visits before commencing Stage 2. Therefore 3 visits need to be added to the above number of sessions. Rousseau et al’s (2007) prospective study reported a median of 16 visits to Stage 2.

Koushik, et al. (2011) did a replication of Jones et al. (2000) for the North American population. Their file audit results replicated the Jones study with a median of 11 sessions to reach Stage 2, but the more severe the stutter the longer the treatment time.

Progress may be influenced by how successful treatment conversations with the child are and how regularly they are occurring. Sometimes, progress is first noticed in structured treatment conversations in that the child is able to say longer and more complex stutter free utterances. This then begins to generalise to reductions in daily severity ratings. It is worth noting that treatment times can be variable and children may respond after several sessions or it can take many months. In all cases if progress is not being observed then it is important to problem solve and consult with colleagues.

References
Jones, M., Onslow, M., Harrison, E., & Packman, A. (2000).Treating stuttering in young children: Predicting treatment time in the Lidcombe Program. Journal of Speech, Language, and Hearing Research, 43, 1440–1450.

Koushik, S., Hewat, S., Shenker, R., Jones, M., Onslow M. (2011) North-American Lidcombe Program file audit: Replication and meta-analysis. International Journal of Speech-Language Pathology, 2011; Early Online, 1–7

Onslow, M, Harrison, E, Jones, M & Packman, A (2002) ‘Beyond Clinic Speech Measures During the Lidcombe Program of Early Stuttering Intervention’ Acquiring knowledge in Speech, Language and Hearing, vol. 2, no. 2, pp. 82-85.

Rousseau, I, Packman, A, Onslow, M, Harrison, E & Jones, M (2007) ‘An investigation of language and phonological development and the responsiveness of preschool age children to the Lidcombe program’ Journal of Communication Disorders, vol. 40, pp. 382-397

I have just qualified as a speech and language therapist, and attended the Lidcombe Program workshop, which I found really interesting. While I understand the principles behind structuring the child’s first sessions, why we do it and so forth, I am a little unconfident about exactly how to do this in the clinic. I wondered whether you could give me some tips about what to do? I know for example that ‘sentence completion’ is a good way to elicit shorter utterances, but could you give me some guidance about other ways of structuring a child’s sessions, and some equipment suggestions? I am hoping to start the Lidcombe Program with my first client in a couple of weeks and he seems to be quite severe, so any suggestions would be really helpful!

The choice of activity and language during a structured activity will be critical to how much stutter-free speech occurs during a structured conversation.

The type of activity being used during a conversation.

Some activities naturally elicit shorter utterances and these are more likely to be stutter-free. For example, playing a memory game or talking about a book with simple pictures allows for a high degree of structure, while playing with toy sets, like train sets or doll houses naturally lends itself to less structured conversation. Books, games, felt boards, puzzles, play dough, drawing/colouring, and magnetic boards are all useful. Many activities can be used for both high and low structure conversations, for example books may elicit very short verbal responses, or can be used to prompt conversations that are much more open ended, free flowing and natural. Books lend them selves to parent training and are the most readily available resource in the child’s home. Still, it is important for therapy to not revolve around only one activity and there should always be variety incorporated into the activity. Also, it is always important to consider the individual child’s preferences and responses: Some activities elicit fluent utterances for one child and not for another.

The linguistic elements of a conversation.

The language used during a conversation can be manipulated to elicit utterances that are of a length and complexity that is more likely to be fluent. Some examples of how a parent might manipulate linguistically are:

1. Modelling:
Children tend to use similar sentences while engaged in an activity to those being used by their parents for example if a parent says: “Look, I see a boy eating an ice cream”, the child might say a sentence of similar length and complexity, for example “yes, and there is a boy kicking a ball”,

2. Sentence completion:
Here a parent begins the sentence but leaves the ending for the child to say, for example, while looking at a book a parent might say, “Wow, that man is climbing….” To which the child may add “up the ladder”. Sentence completion can be used to gradually encourage longer sentences as the child’s fluency improves, for example the parents may say, “Over there is….” To which the child may respond “…a boy eating some popcorn”.

3. Binary choices:
Here a parent limits how much a child says by asking a question that contains two responses: An example is “Is that red or blue?”, Binary choice questions are suitable when a conversation needs a lot of structure, and when stuttering severity is higher.

4. Commenting
This refers to teaching the parent to point at a picture/something and say a word that directs the child’s attention and encourages them to comment, for example the parent might say “Look…” and wait for the child to make a comment.

5. Directing the conversation

6. As the child demonstrates increased fluency the amount of time the parent spends doing that can lessen. The aim of treatment during structured conversation is not to stay at the same level (for example, single word level, or sentence level) but to encourage parents to readily experiment to determine if they can elicit longer and more spontaneous responses from the child whilst continuing to be at a severity rating of 1 or 2, as soon as possible.