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Clearer thinking within the Lidcombe community

Posted Feb 13 2012 7:58am
Finally, reason seems to have come to the Lidcombe community in the words of Ann Packmann's article Why does the Lidcombe Program “work”? Mary Kingston, the editor of the newsletter Lidcombe News , quite neatly summarizes the Lidcombe community's mental bias by asking Ann to answer how Lidcombe works and not whether Lidcombe works. She does not even contemplate the thought that Lidcombe could not work!

Ann answers the how question with "I don't know" and the whether question is very much watered down to a level that I can more or less agree with. She says many things that  I have been preaching all those years...

It's time that the Lidcombe community tones down its claims, and listen to Ann's words. And maybe it's also time that Ann and Mark Onslow should switch posts. She should be professor and he senior research fellow. ;-)

Here are her words together with my comments. Take the time to read carefully!
.... It is a topic that has intrigued me for years, as I am sure it has most people who use the program. Unfortunately, the only short answer I can give is, “I don’t know!”
Saying "I don't know" is a sign of intellectual honesty. It also reveals the weakness of the method. How can you be so sure it works well when you don't even know how it works. Does this not mean that you do not actually know what you are doing? So, a priori, an absence of explanation combined with claims of great successes is always very suspicious.
Having said that, I love to theorise, so I am happy to offer some ideas to ponder on.Does the Lidcombe Program “work”?
First of all, I want to say something about the title, which Mary suggested to me. All too often we say, and we hear people say, that the Lidcombe Program “works”. I think we need to be careful about our phraseology here, because all we know from the research is that the program has an effect on stuttering after 9 months that is greater than that of natural recovery (see Jones et al., 2005). There are people who say that we overplay the efficacy of the program. Perhaps by saying it “works” we are giving the unintended impression that the Lidcombe Program “cures” stuttering in every child. Which it doesn’t. So perhaps it is better to say that the program is “effective”, rather than “it works.”
I have to disagree. People has used far stronger words on their websites and in talks such as "stop stuttering", "remove stuttering", and "makes them fluent". And we critizise those. "Works" does not actually say what works. The same for "effective". Does it work in reducing stuttering, reducing fears, helping parents. Yeah, of course... So this is a straw man.


Having said that, Lidcombe is the only early intervention for stuttering for which efficacy has been demonstrated with clinical trials.
I dispute that this is statistically stable. Effectiveness is also just on 9 months. She should have added a sentence: "But of course that does not imply that other approaches are less effective, just that these have not been tested yet."
And, of course, most of the children we treat with the program recover from stuttering completely, and this is wonderful.
Possible explanation
I think the most likely reason for the effects on stuttering of the Lidcombe Program is the verbal contingencies that the parent gives the child for “smooth” and “bumpy” speech. The message the child gets from this, whether consciously or unconsciously, is that he or she should talk “this” way and not “that” way. We know that children do not stutter on every word/syllable, so it seems that they can somehow draw on this to be more fluent (see Hayhow, 2011, for an interesting discussion of this). How they do this (if in fact that is what they do!) we do not know. We do know, however, that they do not do it by reducing linguistic complexity (Bonelli et al., 2000: Lattermann et al., 2005), so that is comforting.
Fine. I never denied that behavioural therapy shapes behaviours.

Recent brain research is telling us that stuttering is probably underpinned by a “glitch” in the neural processing associated with speech production, especially in the white connecting fibres (e.g. Chang, et al., 2008). I do not see how the program can change this.
WOW. That is the first time someone from Lidcombe says this. And it's exactly my point. And it is  the opposite of what Mark Onslow said to a question I once asked. He said: Of couse, children's brain are plastic.
However, there is some support for the idea that once a child starts talking fluently, this may change structure in a young brain that is still plastic. Those of you who were at the 2011 Oxford Dysfluency Conference may have heard Martin Sommer, an eminent German brain researcher, supporting the idea that this may happen with the Lidcombe Program.
I think that Martin is slightly deluded by statistics here. I told him a million times that the outcome studies are not safe, but he doesn't seem to have understood my arguments. He still assumes that it is effective, and therefore he looks for an answer, and the only answer he can come up with is brain plasticity. And therefore he thinks that is what is happening.

But I don't think it has been proven effective. But plasticity plays a big role, but just for those that recover naturally. Those 80% that do recover, do so because their brain / they manage to re-train themselves / their brain.
However, we know that not all children who initially do well with the program remain fluent in the long term. Our follow up study showed this to be the case (Jones et al., 2008) and I think many therapists have experienced this. It can be distressing to see a child return to the clinic when stuttering reappears after a long period of fluency
Yeah, well that study had so many drop-outs. That the stats are probably even much worse.

I can tell you what happened there. The kids got their behaviours shaped, and became more fluent. But then they lost it, or the neurobiological difficulty got greater and maladaptive behaviours took over again.

My view is that those children who do well with the program and never stutter again may have been predisposed to recover anyway.
WOW. That is exactly what I have been saying. But then tell me. Why do we do Lidcombe? So it doesn't do much at all, except let them recover earlier...
However, for those who respond well but who never actually stop stuttering, either in the short term or the long term, it may be that parental contingencies are needed to keep the stuttering under control. The implication here is that the parent may need to continue providing contingencies, albeit infrequently, for much longer than we think. From what I hear therapists say, parents often stop doing this once the child’s speech is sounding good.
 My word again.

This explanation may at first blush sound depressing, as it suggests there are some children who will never become completely fluent with the Lidcombe Program.
Yes, and the other would have recovered anyway?????????
However, on the positive side, I think it may also have the effect of removing the burden of therapist guilt when a child continues to stutter (the caveat here, of course, is that the program was implemented according to the manual in the first place). Further, if a child’s stuttering can be kept at a very low level with on-going parental contingencies, this has to be a good thing. In this scenario the child is probably much less likely to suffer the social penalties and bullying that we know can occur going in to the school years.
I agree. IF it can be kept at low level. And that is the critical question.
And perhaps this protracted period of fluent, or near fluent speech, will change brain structure for the better, as Martin Sommer suggests. Let’s hope so.
No, I don't think so. It's rather that learned behaviours early in childhood might well stay learned for life but i doubt they will change the brain structure as such.

The explanation I have given also suggests that we are treating many children who are destined to recover anyway. However, I think we already know this (see Packman, Onslow & Attanasio, 2003). And this is justified by some recent epidemiological research here in Australia (manuscript in preparation), which suggests that fewer children recover in the first year after onset than previously thought. Our general rule of thumb, based on available evidence, is that waiting a year before implementing the program is unlikely to jeopardise a child’s responsiveness.
That is a strange argument. First, she seems to argue that to start as early as possible, you can still change the brain. But this window is probably until 3 or 4 the greatest. This does not seem consistent. Either you can wait and plasticity plays no role, or you cannot and it does.
Given that we cannot predict whether an individual child will recover naturally, and the likely negative effects of stuttering on pre-schoolers (Langevin et al., 2009), we cannot leave so many children to stutter for much longer than this before intervening, in the hope that they will recover without treatment.
That is an argument, but is the negative effect permament?

I must say again that this explanation for the mechanism underpinning the Lidcombe Program is hypothetical. I am theorising and trying to find an explanation that best fits the facts, as we know them. However, the hypothesis that contingencies are responsible for the effectiveness of the program is testable; all we need is a randomised controlled trial comparing straight Lidcombe with Lidcombe minus contingencies. For theoretically, at least, it is possible that the mechanism underpinning the program’s effects is simply that parents have positive talking times with their child each day!
No it is not possible because of ethical concerns? Did you not have to stop the outcome trial because parents revolved?
Conclusion
Does the explanation I have given have implications for how we do the Lidcombe Program? I think all we can do is to continue to deliver it as best we can but encourage parents to continue giving contingencies for smooth speech and for stuttering (if the child has residual stuttering) in the long term, after the conclusion of Stage 2. Here at the ASRC, Sue O’Brian and the team are investigating the use of fridge magnets to remind parents to do this. Stay tuned!
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