2021 SPHY304 Week 4 Lecture

9/08/2021
Fluency Disorders Across the Lifespan
SPHY304 Lecture Week 4

Lidcombe Program
Stage 2 Problem Solving
Telepractice & Group Delivery
Bilingualism and Stuttering
Intro to School Age: a complex
age group
Michelle Donaghy 2021
Lidcombe Program
Stage 2
https://www.flickr.com/photos/sanjoselibrary/2840033867
Stage 2
• AIM: Maintain stutter-free speech

• Gradual reduction of therapy over a year
(Performance Contingent)
• Suggested: 2 x Fortnightly, then 2 x 4 weekly, 2 x 2
months, then 4 months apart
• Problem Solving occurs when stuttering increases
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Stage 2
• Parents need to know the child is vulnerable

• Parents can be encouraged for getting this far – but
they don’t want to waste all that effort by stopping
now!
• Parent ‘empowerment’
NB a ‘return to Stage 1’ isn’t named as usual practice,
however, increasing frequency of clinic visits until
Stage 2 aims are resumed (3 weeks of little or not
stuttering, mostly SR0) is possible
Stage 2
• Ask ‘How many times would you comment on

stutter-free speech?’
• Ask ‘How many times would you respond to

stutters?’
• Gradually reduce verbal contingencies
Stage 2
• Parents tend to increase amount of verbal
contingencies for stuttered speech (Swift, et al, 2011)
• Parent scores for SRs in the week before each

session (or more if concerned)
• Clinician may advise to return to more structure (ie

Practice Sessions) in conversations if child is not
maintaining Stage 2 criteria
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Has Lidcombe Program Cured

my Child for Life?
• Not necessarily
• ~50% of children relapse may occur (Jones et al,
2008)
• Awareness important (alert, but not alarmed???)
• The stutter might return – or not.
Lidcombe Program Problem Solving

– Participate in the Forum!!
What Problems are likely to occur?
✓ Your ‘Engagement’ task this week is to

participate in another National SPHY304 forum.
✓ This task will help you think about the problems
that might occur in the Lidcombe Program – or
in early stuttering intervention generally.
WHY???
By pre-empting possible problems, you are better
prepared if they happen.
Lidcombe Program Problem Solving

– Participate in the Forum!!
Participate in the online forum by answering either

one of the following questions:
a) What problems might occur at the beginning of
treatment?
b) What problems might occur prior to a child
reaching little or no stuttering?
c) What problems might occur in Stage 2?
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Lidcombe Program Problem Solving – Participate in the Forum!!
✓ You could think about problems specific to

the impairment…BUT you can also:
✓ Think about possible childhood
characteristics.
✓ Think about the day to day problems that
families encounter.
✓ Let your knowledge about the ICF guide you
too
✓ Read suggested article about problem
solving in this chapter!! (van Eerdenebrugh
et al., 2018)

This Photo by Unknown Author is licensed under CC BY-NC-ND
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Telepractice & Stuttering
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What is Telepractice?
• Also known as telehealth, eHealth.
• Telehealth is the use of information technology and
telecommunication systems to deliver and / or support health
services (Project for Rural Health Communications and Information Technology, 1996)
• Different modes:
✓Telephone
✓Webcam
✓Email
✓Teleconference
✓Smartphone/Tablet Apps
✓Websites
✓Other? Read the Online Tutorial readings for this week and
find out!
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What is Telepractice?
▪ The client and therapist can be anywhere as long
as they have the technology
▪ Used extensively in medical services
• Increasingly in Speech Pathology (E.g. Telestroke)
• Assessment of apraxia of speech in adults
(Hill, Theodoros, Russell, & Ward, 2008),)
• Hypokinetic dysarthria (Theodoros et al., 2006),
▪ Viable alternative to within clinic delivery of
treatment
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Telepractice - Access
• Geographical remoteness
• Disability hinders attendance
• No reasonably accessible local options
 Transportation issues
 Availability of appointments / times
 Family commitments
 Work commitments
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Telepractice –
When would you use it?
Consider….
• Evidence: Is Telepractice non-inferior* to face to
face? How do you know?
• Weighing up other options
• Accessibility issues
• In consultation with client
• Available technology resources
*non-inferiority trials
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Telepractice – The Lidcombe

Program
Telephone (& Mail)
Harrison, Wilson, & Onslow (1999)
- Single Case Study
Wilson, Onslow & Lincoln, (2004)
- Phase I trial – N= 5, ages 3;5 – 5;7
Lewis, C., Packman, A., Onslow, M., Simpson, J. M., &
Jones, M. (2008)
- Phase II Trial: Random allocation to treatment
group or control group
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Program
Telephone
• Not as efficient – but it works, and may be best
alternative for some
• Problems: not delivered weekly, or to LP Manual
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Program
O’Brian, Smith & Onslow, 2014
• Phase I, 3 Preschool children
• Internet & Webcam
• Met benchmarks for LP
• Forerunner to the RCT
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Program
Bridgman et al, 2016
• n = 49
• RCT of telehealth delivery (non-
inferiority)
• Webcam delivery of LP vs standard
within clinic treatment
• Measures at 9 & 18 months
• Not inferior to standard LP Tx
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Program
Bridgman et al, 2016
‘Ground Rules’ required ….

• Stay with the child
• Attend on time
• Be punctual & focussed
• Any guest should be visible
Dr Kate Bridgman
• Not recorded
• Cancellation policy/rules
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Telepractice – Camperdown Program
O’Brian et al., 2008

• Phase I trial, 10 participants, telephone & exemplars
used
Carey et al., 2010
▪ RCT, Webcam, Telehealth delivery vs face to face
(20 randomised to each group, 3 DOs)
▪ Non-inferior to face-to-face delivery
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Telepractice – Camperdown
Program
Carey et al., (2012)
• Phase I clinical trial,3 adolescents who
stutter, Camperdown Program, Skype
• Efficacious, efficient and appealing
Carey, O’Brian, Lowe & Onslow (2014)
• N= 16, data taken 12 months post
maintenance
• Appealing for adolescents, but only
efficacious & efficient for half.
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Telepractice – Camperdown
Program
The following article will be VERY USEFUL for your
Telepractice Adult Stuttering assignment:
Carey, B., O’Brian, S., Onslow, M. (2015). Technology in
Practice. Journal of Clinical Practice in Speech -
Language Pathology, 17 (3).
Lowe, R., O'Brian, S., Onslow, M. (2013). Review of
telehealth stuttering management. Folia Phoniatrica
Logopedia, 65, 223-238. DOI: 10.1159/000357708
Also read:
Bridgman, K., Block, S., & O’Brian, S. (2015). Webcam
delivery of the Lidcombe Program. Journal of Clinical
Practice in Speech - Language Pathology, 17 (3).
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Telepractice – Other Therapies?
Question: When would you use

Telepractice with other stuttering treatment
optons?
Answer: When it was the only feasible
option…
Think of your E3BP Rationale…
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Telepractice and other Types of

Stuttering Treatment
• 10 year old
• Very unmotivated to do LP as he says ‘it’s babyish
and doesn’t work anyway’.
• Getting bullied at school and is beginning to withdraw
• Parents can’t get to the clinic, can’t get off work as
they both work long hours
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Telepractice and other Types of

Stuttering Treatment
External: The science to support telepractice in stuttering
and other RoP areas and there is evidence to support STS
for school age children
Internal: Your 10 year old client has a severe stutter, LP no
longer works for him, so STS is your next best option
Client Needs: The child is getting bullied at school, and
stuttering increases when he is asked to read in the
classroom. Parents unable to attend the clinic, but there is a
teacher’s assistant who is willing to support telehealth and
‘check in’ with the client, and parents are able to attend one
session and communicate via email/phone to support at
home.
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Issues that may arise…

▪ Setting boundaries
▪ Keeping appointments
▪ Trouble shooting IT
▪ Keeping it professional
▪ Keeping the child at the screen!
▪ Would other stuttering treatments be suitable for
Telehealth?
▪ And anything else??
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Group vs. Individual delivery

of the Lidcombe Program
Arnott et al., 2014
Thanks to Dr Simone Arnott for the following slides on Group LP Delivery
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Efficiency Efficacy
• Number of Clinician
hours per child to • Stuttering
Stage 2 Frequency
• Number of
sessions to Stage 2
• Number of weeks
to Stage 2
Simone Arnott, 2016

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Median Clinician hours to Stage 2
Saving 46%
Clinician Hours per Child
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Median Sessions to Stage 2
Simone Arnott, 2016
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Median Weeks to stage 2
Simone Arnott, 2016
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Stuttering frequency
Assessment 9 months 18 months
Individual
4.4 1.1 0.8
Mean %SS
Group
4.0 0.9 0.8
Mean %SS
Simone Arnott, 2016

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Conduct a Preliminary Training

session
During the PTS you will:
• discuss Severity Ratings,
• allocate the child a within clinic Severity Rating,
• obtain a percentage of syllables stuttered rating if you
wish,
• discuss stuttering types and develop the parent’s
discrimination of their child’s stuttering, and
• demonstrate a practice session.
• You may also discuss parental verbal contingencies and
demonstrate provision of these.
Simone Arnott, 2016
34
Then Group Visits Begin

• Children engage in free play or sit with their parents
• In a group, parents report their weekly SRs
• Discuss SRs
• You and the parents will then talk with the children or just
listen in to their conversations…
• allocate a within clinic SR for each child when you have a
sufficient sample.
• set up some treatment conversation for the parent-child
pairs. This might be done in a group or at individual tables or
work stations. You’ll decide this based on the group
dynamics and the SRs of each child.
Simone Arnott 2016

35
• The parents administer treatment conversations and

receive demonstrations and feedback from you.
• If the parent-child pairs are at separate tables, you
will ‘cruise’ the room to provide each parent with
some individual time.
• If everyone is doing their treatment conversations
together, then you’ll listen in to each pair as they do
the group activity.
• Parents gather for a group debrief, discuss new
learning and set goals for the coming week
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• Remember, Stage 2 is individual

• When one parent child pair is ready to enter
Stage 2, you need to consider if you want to
run ‘rolling groups’
ALSO Check out…

Evidence for rolling group delivery:
Rappell, N. & Schmidt, D. (2017). Rolling-group Lidcombe

Program Perspectives from participant clinicians in a
community- based cohort study. Journal of Clinical Practice in
Speech-Language Pathology, 19(2).
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Stuttering and Bilingualism
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Stuttering & Bilingualism FAQs
• Does my child stutter because he speaks two

languages?
• Can a speech pathologist assess a stutter in a
language other than their own?
• Is therapy as effective for bilingual/multilingual
clients?
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Stuttering & Bilingualism FAQs
• Does my child stutter because he speaks two

languages? NO.
• Can a speech pathologist assess a stutter in a
language other than their own? YES…BUT…
• Is therapy as effective for bilingual/multilingual
clients? YES!
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• Stuttering occurs across cultures and languages as
well as in bilinguals and monolinguals (Van Borsel, et al.,
2001).
• Stuttering as common in monolinguals as bilinguals
(Au-jeng et al., 2000)
• Multilingual PWS might report differences in severity of
their stuttering between the languages, most $ in both
(Howell, Davis & Williams, 2009)
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• Determining stuttering in a another language –
check with parent (Cordes, 2000)
• Ax fluency in both languages (Shenker, 2004)
• Single case studies show fluency Rx in one

language carries over to the other (Shenker, 1998;
Humphrey, 1999)
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Study - English & Mandarin

(Lim et al., 2008)
Are English/Mandarin Bilinguals different in type

& severity?
Does language dominance matter?.
N= 30 bilinguals who stutter (BWS) :
 15 English dominant
 4 Mandarin dominant
 11 Balanced bilinguals
Speech Measures: 3 x 10min conversations in
both languages
 %SS
 LBDL
43
Findings (Lim et al., 2008)
• Higher %SS scores and severity ratings across

English dominant and Mandarin dominant BWS for
their LESS DOMINANT language.
• Balanced bilinguals showed similar %SS and severity
ratings across both languages.
• Stuttering behaviours (LBDL analysis) were not
significantly different between English and Mandarin
44
Findings (Lim et al., 2008)

- Participants (n=14) had intensive speech restructuring
program in English - Post Rx speech measures were
taken:
◦ Post Rx,
◦ 4 weeks post Rx
◦ 12 weeks post Rx
Analysed by Mand/Eng bilingual SLPs
- ~69 – 85% redux, both languages
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What do these findings tell us?
• Language dominance could impact

stuttering severity in a non-dominant
language
• Ax stuttering in both languages
• Consider management for BWS when
working in non-dominant language
environments
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Children from bilingual and

Non-English speaking backgrounds
Lidcombe Program
- Case study with an English/French bilingual
preschooler
- Clinical trial with German speaking preschoolers
- Clinical trial with Malaysian and Kuwaiti
preschoolers in progress
- 4 case studies in Malaysia (Vong et al, 2016)
- Case study School Age Iran (Bakhtiar &
Packman, 2009)
Language does not appear to be an issue but culture
might be. Why do you think?
47
Children from bilingual and

Non-English speaking backgrounds
Looking for something to help you with bilingual families?
Vong, Wilson, McAllister & Lincoln (2010)
Malaysian Parents' Use of Positive Reinforcement: A
Descriptive Study and Implications for the Lidcombe
Program, Asia Pacific Journal of Speech, Language and
Hearing, 13:2, 87-108,
DOI:10.1179/136132810805335119
Etain Vong’s PhD thesis is also available free online!
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Another thought....
Does Stuttering Occur in Sign
Language?
• Inconsistency of signal in sign and finger-

spelling
• $ing occurs often at initiation of gesture
• Hesitations, repetitions
• Exaggerated, ?prolonged sign
49
Stuttering & Sign Language

cont.
Superfluous movements unrelated to gesture &
inappropriate muscular tension during signing
Poor ‘fluidity’ (?fluency) of sign
(Honors Thesis, Whitebread, 2004)
Interesting stuff, but little research done....

See the following article from Greg Snyder,
University of Mississipi (2006) for more
information:
http://www.mnsu.edu/comdis/isad9/papers/snyder9.html
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Starting School 6 – 12 years

Adolescence 12 years +
Early School Age – Concrete Operations
✓ Transformational thought – understands change
✓ Seriation & Transitivity – understands order and works
things out in their heads
✓ Mastery Oriented
✓ Learning Goals
Clinical Considerations
✓ Verbal RCS –
immediate feedback
✓ Adult guided goals
52 Michelle Donaghy
52

 Adolescence – Formal Operations
• Hypothetical & Abstract Thinking - awareness of the
real consequences of how they present to others
• Problem Solving – ‘bigger picture’ thoughts
• Decline in achievement motivation (Gutman, Sameroff & Cole,
2003)
• Performance goals
 Clinical Considerations
✓ Rewards & Punishments
(RCS) no longer satisfying
✓ ‘Bigger picture’ fluency performance
53 Michelle Donaghy
53
Moving to Adolescence
Conformity
• To parents – gradual and steady decrease
• To peers – increases to 14-15 years, then declines
Self- View
• Self-descriptions become less physical and more
psychological as children age
• Self-portraits become less concrete and more abstract
• Moving towards a differentiated self - splits in child’s
‘social self’
54 Michelle Donaghy
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Clinical Considerations
 Increasing independence in therapy
 Peer perspectives matter – social penalties matter
 Self-driven treatments important (ie speech
restructuring)
 Anxiety & Fear of Negative Evaluation more likely
 Self-motivation and resilience matters
55 Michelle Donaghy
55
The Continuum
~6 years ~18 years
• Cognition-Concrete • Cognition - Formal

Operations Operations
• Concrete thought • Abstract thought
• Dependant • Independent
• Mastery goals • Performance goals
• Conform to adults • Conform to peers
• Physical Self- • Psychological Self
Concept Concept
• Physical Immaturity • Physical Maturity
56 Michelle Donaghy
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Video – Joanne & Nathan

from ‘Help Me to Speak’
 Watch the Youtube video in this
chapter
 Describe the way each child talks
about themselves
 What issues might be different at
different ages?
57 Michelle Donaghy
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What else do we know about

stuttering at different ages?
 Early stuttering
✓ Onset <5 years
✓ Variable in severity
✓ Good treatment response (highly tractable)
✓ ~ 90% success rate using Lidcombe Program (Onslow,
2017)
✓ Less likely to be aware/troubled by stutter

✓ Fluency outcomes more dependant on parental
guidance
✓ Minimal peer evaluation of stutter likely
58 Michelle Donaghy
58

 Advanced (school age/adolescent/adult) stuttering
✓ Long time post onset
✓ Severity often context driven
✓ Complete recovery unlikely, stuttering less tractable
✓ Fluency outcomes more dependant on self
motivation
✓ School age Tx success varies depending on the
individual using LP (Koushik et al, 2009) and STS (Andrews et al, 2016)
59 Michelle Donaghy
59

 Advanced (school age/adolescent/adult) stuttering
✓ Negative evaluation starts in preschool (Langevin et al,
2009; Ezrati-Vinacour et al, 2001) and continues to increase at
school (Daniels et al, 2012; Flynn & Louis, 2011)
✓ Increased risked of social phobia/anxiety/FNE,
compared to non-stuttering peers (Iverach et al, 2016)
✓ Reduced opportunities in education and vocation
(Daniels et al, 2012; Davis et al, 2002; O’Brian et al, 2011)
✓ Vulnerability increases once child gets to school and

continues to increase (Smith et al., 2015; Gunn et al., 2013, Mulcahy et al,
2008)
60 Michelle Donaghy
60
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School Age – 6 – 12 years
• Class Teacher may be the only

advocate
• Limited access to SLP resources &
knowledge about stuttering
• Needs to assess & report on student
• Important in helping transition to High
School
61 Michelle Donaghy
61
High School – 12+ Years

• Many teachers – less opportunity to get to know
students
• Often more students in classroom
• Year Advisor/Counsellor/Welfare team important
• Negotiating with student essential
62 Michelle Donaghy
62
From Primary to High School

 Discuss with the child whether they would like you
to contact his/her teacher (primary) or the Year
Advisor (secondary)
 Consider providing a summary/report
 Read the ‘Fluency Summary’ example
 Create assessment tasks and interview questions
that would give you the information that is provided
63 Michelle Donaghy
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The Role of Teachers
MORE LATER…and in the

Week 8
Mandatory Guest
Lecture
64 Michelle Donaghy
64
22

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9/08/2021

Fluency Disorders Across the Lifespan

SPHY304 Lecture Week 4

Michelle Donaghy 2021

• AIM: Maintain stutter-free speech

Michelle Donaghy 2021

• Parents need to know the child is vulnerable

Michelle Donaghy 2021

• Ask ‘How many times would you comment on

• Ask ‘How many times would you respond to

• Gradually reduce verbal contingencies

Michelle Donaghy 2021

• Parent scores for SRs in the week before each

• Clinician may advise to return to more structure (ie

Michelle Donaghy 2021

Has Lidcombe Program Cured

Michelle Donaghy 2021

Lidcombe Program Problem Solving

✓ Your ‘Engagement’ task this week is to

Lidcombe Program Problem Solving

Participate in the online forum by answering either

Michelle Donaghy 2021

Lidcombe Program Problem Solving – Participate in the Forum!!

What Problems are likely to occur?

✓ You could think about problems specific to

Michelle Donaghy 2021

Telepractice & Stuttering

Michelle Donaghy 2021

Michelle Donaghy 2021

Michelle Donaghy 2021

Michelle Donaghy 2021

Michelle Donaghy 2021

Telepractice – The Lidcombe

Michelle Donaghy 2021

Telepractice – The Lidcombe

Michelle Donaghy 2021

Telepractice – The Lidcombe

Michelle Donaghy 2021

Telepractice – The Lidcombe

Michelle Donaghy 2021

Telepractice – The Lidcombe

‘Ground Rules’ required ….

Michelle Donaghy 2021

Telepractice – Camperdown Program

O’Brian et al., 2008

Michelle Donaghy 2021

Telepractice – Other Therapies?

Question: When would you use

Think of your E3BP Rationale…

Michelle Donaghy 2021

Telepractice and other Types of

Michelle Donaghy 2021

Telepractice and other Types of

Issues that may arise…

Michelle Donaghy 2021

Group vs. Individual delivery

Thanks to Dr Simone Arnott for the following slides on Group LP Delivery

Michelle Donaghy 2021

Simone Arnott, 2016

Median Clinician hours to Stage 2

Median Sessions to Stage 2

Simone Arnott, 2016

Median Weeks to stage 2