The Libcombe Programme: some reflections
by Rosemarie Hayhow, Specialist Speech and Language Therapist, Bristol.
Earlier this year I was fortunate in receiving a BT bursary to travel to Australia to spend two weeks studying the Lidcombe programme of Early Stuttering Intervention. I'm taking this opportunity to share some thoughts in a practical rather than an academic way.
There are at least two important questions that I think the discussions around the Lidcombe approach have raised. Firstly, should therapy aim for fluency or acceptance of stammering (i.e. is stammering OK or is it a handicapping condition not just because of how others respond but because of the effect it has on the child's experience of self?). Secondly, does the child need to learn to control their speech disruption or can it me minimised/eliminated by the behaviour of others?
Onslow and his colleagues have fewer problems with these questions than UK therapists, perhaps because of their more consistent behavioural tradition. They view stammering as a handicapping condition that the child needs to learn to manage. They can go further and say that on the basis of their longer term results it looks as though many children are able to learn to deal with their stammering in the pre-school years and that it does not recur. Whether this is because they cease to experience any pre-stammering type sensations or whether some continue to but automatically deal with these sensations in such a way that speech isn't disrupted we maybe won't know until these children are older and able to talk about such things. Maybe they learn to monitor for potential fluency disruption on the same low level of awareness as we modify our production of sounds to maintain a uniformity or the way we sift vocabulary. Things that are done so habitually that we don't even register that we've done anything. Discussions over the years with people who've stammered as children but not as adults suggest there are some who continue to experience the forewarnings of speech disruption, especially when tired, unwell etc. but they have leant to respond to these sensations in a positive, coping way. I think it likely that some to the young stammering children we see continue to have problems with fluency as they develop but for others it is a more transitory developmental problem and provided they don't build up all the secondary problems they experience fewer and fewer pre-stammering sensations. What is very clear with the children I've worked with so far, using the Lidcombe approach, is that all become very much more fluent in the first few weeks but the level of remaining stammering is variable, suggesting to me that there are differences between the children in how easily and consistently their vulnerable speaking systems are stressed. Those who are left with some stammering after the first few weeks need more therapy and more on-line feedback to bring their level of stammering down.
I hope that people reading this will feel motivated to respond to these questions, I think we need to debate issues around the nature of early stuttering. Onslow's claims to eliminate stuttering in young children and David McGuire's work with adults have put fluency back on the agenda and shown us that for many parents and for many adults who stammer this is what they want. We have been made wary of setting unrealistic targets and are very aware of the inherent dangers in short lived fluency. However, if we can work with children early enough then is seems that we may be able to help, at least some of them, learn to deal with their stammering in constructive ways and speak fluently without fear or avoidance of stammering. In addition, because children are encouraged to find their own ways of 'correcting' their stammer we are not imposing an unnatural speaking pattern.
The concepts behind the Lidcombe programme are simple: stuttering in young children is an operant behaviour, it is caused by a motor speech difficulty that only becomes apparent when the child begins to join words together into short sentences (possibly triggered by the need to de-stress syllables see - Packman et al. 1996). Systematic reinforcement of fluent speech will lead to an increase in fluency and requests for correction will encourage a child to find adaptive ways of dealing with their speech disruption. The programme is only intended for children who have begun to develop maladaptive ways of dealing with their speech disruptions i.e. are consistently showing signs of stammering and have been doing so for some time. It is argued that these children need to find their own ways of handling their stammering and that without help they are likely to develop a more severe problem. In fact, many of the children who we saw receiving therapy had to wait for several months after their initial assessment. They were only put on the treatment waiting list if they were clearly stammering and the wait for therapy gave a further chance for the children to develop out of their problem of their own accord. So all the children we saw receiving therapy had been stammering for the best part of a year and there is increasing evidence that children's chances of spontaneous recovery from stammering reduce markedly once they have been stammering for this long.
The approach has been criticised for its simplicity but the therapy is not simplistic. Therapist and parent are actively engaged in problem solving as they find ways of firstly increasing fluency to provide opportunities for reinforcement and then gradually increasing the disfluencies so that the child has opportunities to 'correct' while still speaking sufficiently fluently to have plenty of positive feedback. This is the basis of the structured talking times which therapist and parent do with the child in the first stages of therapy. In the next stage the talking times are reduced and the child, who is now speaking more fluently, is given on-line feedback.
While I'm writing, I'm thinking of a five year old who I saw for the first time earlier today. He's had two years of intermittent speech therapy for speech and language delay. He has done well but there are still some immaturities and he lacks confidence in his speaking. He has been stammering for some time. I found that he was consistently fluent as the one word level and so that is where we started for his talking time with me. His face really lit up in response to my positive feedback and he began to utter the single words with increasing fluency and confidence. I risked some slightly more spontaneous speaking and at first this was OK and then he started to stammer, quite badly, on the first phrase of an utterance. He paused and started again, this time fluently. His parents were delighted, they had never seen him able to handle his stammering before and the child realised he'd managed something new - he really grinned. I'm retelling this not because it's the first time I've experienced such a swift and positive response but because I have now seen quite a few children respond in this way. It would be ridiculous to suggest that all start so well with therapy or that it necessarily continues to go so well. As everyone knows there are many factors that influence how quickly a child learns to speak more fluently and the parent's ability to grasp the underlying principles and then put these into practise also has a tremendous effect. For some years now I've felt concerned that I haven't been effective enough with some of the young children I've worked with. I've wanted to be more direct because the pattern and type of stammering that they experience has seemed to need direct modification. It was a tremendous relief to observe the work of a sensitive and experienced team who have learnt some excellent ways of helping children develop adaptive responses to speech disruption.
Are there risks in this approach? Yes I think so. The balance between praise and requests for correction is crucial and will be different for different children. It is also important that initially the feedback on fluent speaking is done consistently and only during the talking times. Children seem to respond very positively to the talking times and don't feel under any personal threat in the way that they might if on-line feedback was given too early. I used the word 'praise' as a sort of shorthand. It's not just praise; it's identification, it's letting the child know when they've got it right and in this way is very similar to phonological therapy or anything else a child learns. They need to know when they are doing it right before they can begin to 'correct' their mistakes. Another area of of potential difficulty arises if the therapist isn't clear about the process of therapy. Parents are very different and learning how to adapt the ideas to ensure a supportive learning environment for the child takes skill and experience. Those of us who went to Australia were impressed by the creativity and flexibility of the therapists, and we learnt a great deal from watching them. Therapists also need to enjoy a problem solving approach and must be able to think on their feet. This approach is not programmed - each week's work is planned on the basis of the progress of the week before. This means that some sort of support network is necessary to avoid the therapist getting stuck.
I find it difficult to view the approach entirely in behavioural terms - when a child smiles as the one described above, I see that as a sign of reconstruing his speaking. Using the words 'smooth' and 'bumpy' help the child relate speaking difficulty to something more tangible rather than the awful experience of being stuck. The therapists in Australia were tolerant of the different meanings I attached to some things. They are committed to a behavioural model but are aware that things can be interpreted differently. The same perhaps is true for the parents and child, we don't know for sure what changes in their thinking and feelings lead to more constructive behaviours. I think we can argue needlessly about who is right and who is wrong.
What I think is important is that we can understand what we are doing, that it makes sense with reference to some body of knowledge or theoretical framework and that we are sensitive to the effects of our interventions. The therapists we observed in Australia used a theoretical framework that I can accept at some levels but struggle with at others. However, there was a great deal that we had in common, more than I had expected, and the areas of potential disagreement were less important than the areas of agreement.
The therapists at Bankstown have modified their therapy in many ways over the years of using the approach and are constantly striving to test out the different beliefs and questions they have. The relationship between Mark Onslow and his colleagues at the University and the clinicians at Bankstown was one of support and challenge. It was a real pleasure to see them combining their different areas of skill and expertise to continue to refine and develop the best possible way of working with stammering children. That they are collecting data for the rest of us to scrutinise is also very much to their credit. In some ways we are very fortunate in the UK. We have access to a wide range of ideas and a variety of approaches to select from. I think that when new approaches come along which have validity and credibility for our clients it is important that we look for what is good in them and use this new knowledge and skill to the benefit of our clients.
When we were in Australia, and since we've returned, we've been asked whether we would be training other therapists. Our initial response was cagey. We wanted to be sure that we could use the approach and that our results were good enough for us to feel confident that we should be adding something to the existing pool of knowledge and skills. The fact that we are all to be involved in courses run with Sue O'Brien in the New Year (ie 1998-Webmaster) show that we have confidence in the approach and feel that it fills a gap that we have not been alone in noticing.
Onslow, M., O'Brien, S. & Harrison, E. (1997) The Lidcombe Programme of Early Stuttering Intervention: methods & issued EJDC Vol 32 no.2 231-266
Packman, A., Onslow, M., Richard, F. & Van Doorn, J. (1996) Syllabic stress and variability: a model of stuttering. Clinical Linguistics and Phonetics Vol 10 no.3 235-263.
Published in the Autumn 1997 edition of 'Signal', the journal of the Royal College of Speech and Language Therapists' Special Interest Group in Disorders of Fluency .
(Reproduced here by kind permission, Webmaster)
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