Therapy for young children who stutter: Efficacy is in the eye of the beholder
Treating developmental stuttering in its incipient stages makes
intuitive sense, especially considering the propensity for the
disorder to cement itself within the central nervous system, making
it highly resistant to treatment at later stages (i.e., in adolescents
and adults). However, regardless of therapeutic intervention,
Mother Nature appears to have her own recovery agenda,
allowing 74% (by these authors admission) of children incipiently
stuttering to complete recovery. For much of the first 50 years of
speech pathology's professional development, the world followed
Wendell Johnson's protocol, which simply advocated removing
unwanted attention from stuttering behaviors1. Because of what
we now understand about these natural recovery rates, we can
clearly see how Johnson created an illusion of therapeutic
success when 74% of his young patients were pre-ordained to
recover. However, for those children that continued to stutter,
implicit blame and guilt were cast a shadow upon the parents for
labeling and reacting to their child behavior and drawing negative
attention to their speech.
Our understanding of stuttering has come a long way
since the Johnsonian days and though the approach to treating
children is now diametrically opposite (i.e., we now advocate direct
intervention), it is still implemented with the assumption that taking
advantage of early neural plasticity is the best recourse for halting
the stuttering pathology. The question is, are the results achieved
nowadays any better? The Lidcombe program provides a parent-
based behavioral, response contingent approach to stuttering. In
this therapy, parents attempt to reduce stuttering by presenting
verbal positive affirmations for fluent speech behaviors and for
reducing " bumpy speech”. The ability of these children to reduce
their stuttering in front of clinicians is not new. Employing parents
as clinicians and collecting data in multiple settings is a new
approach in stuttering therapy and seems the signature of the
Lidcombe program, yet still does not eliminate a potential
Hawthorne effect during data and does not mean that any
observed reduction or elimination of stuttering occurs across
speaking environments and situations. Short-term reduction in
stuttering frequency is easy to demonstrate with any kind of
therapy2, whereas recovery appears to be difficult to achieve in
persistent stutterers at any stage of development.
Lidcombe behavioural therapy has been practiced for
over a decade. Its popularity has spread across the globe. In fact,
specialized manuals and training centers exist to help clinicians
become proficient in implementing Lidcombe procedures. Now, in
this day of "evidence-based" therapy, the first randomized trials by
these authors should be applauded. They took substantial efforts
to ensure that groups were adequately randomized and balanced,
the treatment was administered according to protocol and the
'counting of stuttering' was conducted by observers who were blind
to treatment allocation. However, knowing the natural recovery
rates, we are unsure whether the advantages of employing an
untreated control group outweigh the fact that a potential remedy
was withheld from children during a critical time in the pathological
development. Regardless, the authors suggest that the results
support the 'efficacy' of the Lidcombe program. An important
question in this study is how efficacy is defined. In this case,
efficacy may merely be an acceleration of the natural healing
process in those children prone to recover or a simple temporary
reduction in stuttering that that can occur with any therapeutic
program for incipient stuttering.
For any program to be considered truly effective in the
treatment of incipient stuttering it should be able to 'beat' Mother
Nature and show complete recovery (i.e. forever free from all
stuttering symptoms in most situations and the perception of being
a person who stutters) rates in excess of 74%.3 However, since its
inception, one of the main points of contention with this program,
as well as others that claim efficacy in remedying childhood
stuttering, has been the separation of therapeutic effects from
those of natural 'spontaneous recovery'. In this study, 134 children
were referred for research program but the results are only
reported 47 children, although the other children may have not
meet some research-imposed criteria it would have been very
informative to see the natural progression of the disorder. As a
group these 47 children demonstrate a mild to moderate
pathology, the use of mild to moderate children is typical of this
research group when they show results of less than 1 or 2%
stuttering.4 Results show that after nine months the mean
stuttering frequency in the treatment group was still 1.5%, with only
52% of children showing a stuttering frequency of less than 1%.
Additionally, in an earlier investigation into the impact of Lidcombe
program on early stuttering, the mean stuttering frequency
following a 12 week treatment was 3.5 % syllables stuttered,5
indicating that traces of stuttering were most likely still evident in
many and the pathology may be subject to 'balloon' again at a later
date. These data show no evidence of complete recovery
exceeding 74%. Therefore, this program cannot claim to heal any
child that would not be otherwise remitted if simply left under the
care of Mother Nature. Similarly, Franken et al. (2005)6 compared
the Lidcombe approach to a Demands and Capacities approach
and both treatments yielded similar positive outcomes. We suggest
that almost all therapies can be helpful in alleviating some of the
symptoms of childhood stuttering.7 The simple fact that children
are learning some means of temporarily 'inhibiting' stuttering in
nurturing environments (e.g., with parent therapists) can help ease
the burden of stuttering and train coping mechanisms. For those
who are likely to recover anyway, almost any type of therapeutic
intervention may accelerate the process. Thus, it is doubtful that
the Lidcombe or any other behaviorally based program is powerful
enough to rewire neural networks and alter the epidemiology of
stuttering. Treating children who stutter may be analogous to
attempts to increase adult height by administering human growth
hormone to children who are not growth hormone deficient.
Though short periods of accelerated growth can be observed, the
final height attained is often similar to what matched children
achieve without the hormone treatment.8 In other words,
regardless of therapy, Mother Nature still seems to have the final
word on who recovers and her agenda is not fooled by temporary
periods of accelerated gains.
We are advocates for providing children who stutter with
all the help in the world. Accelerating recovery and providing
stuttering children with means of coping with the pathology
remains a most noble cause. However, when employing the
Lidcombe program and stuttering persists, we must also caution
against falling into the Johnsonian snake pit of blaming parents for
an involuntary childhood pathology whose full recovery is most
likely beyond their control.
References:
1. Johnson W. A study of the onset and development of stuttering.
In Johnson W, Leutenegger RR, eds, Stutttering in Children and
Adults. Minneapolis: University of Minnesota Press, 1955.
2. Bloodtein O. A Handbook on Stuttering. San Diego, CA:
Singular Publishing Group, 1995.
3. Kalinowski J, Saltuklaroglu T, Dayalu V, & Guntupalli VK. Is
it
possible for speech therapy to improve upon natural recovery
rates in children who stutter?. Int J Lang Comm Disord
2005;40:349-58.
4. Onslow M, Andrews C, Lincoln M. A control/experimental trial of
an operant treatment for early stuttering. J Speech Hear Res
1994;37:1244-59.
5. Harris V, Onslow M, Packman A, Harrison E, Menzies R. An
experimental investigation of the impact of the Lidcombe Program
on early stuttering. J Fluency Disord 2002;27:203-14.
6. Franken MC, Schalk CJ, Boelens H. Experimental treatment of
early stuttering: A preliminary study. J Fluency Disord, doi:10.1016/
j.jfludis.2005.05.002.
7. Kalinowski J, Dayalu VN, Saltuklaroglu, T. Cautionary notes on
interpreting the efficacy of treatment programs for children who
stutter. Int J Lang Comm Disord 2002;37:359-61.
8. Kawai M, Momoi T, Yorifuji T, Yamanaka C, Sasaki H, Furusho
K. Unfavorable effects of growth hormone therapy on the final
height of boys with short stature not caused by growth hormone
deficiency. J Pediatr 1997;130:205-09.
Rapid Response:
Therapy for young children who stutter: Efficacy is in the eye of the beholder
Treating developmental stuttering in its incipient stages makes
intuitive sense, especially considering the propensity for the
disorder to cement itself within the central nervous system, making
it highly resistant to treatment at later stages (i.e., in adolescents
and adults). However, regardless of therapeutic intervention,
Mother Nature appears to have her own recovery agenda,
allowing 74% (by these authors admission) of children incipiently
stuttering to complete recovery. For much of the first 50 years of
speech pathology's professional development, the world followed
Wendell Johnson's protocol, which simply advocated removing
unwanted attention from stuttering behaviors1. Because of what
we now understand about these natural recovery rates, we can
clearly see how Johnson created an illusion of therapeutic
success when 74% of his young patients were pre-ordained to
recover. However, for those children that continued to stutter,
implicit blame and guilt were cast a shadow upon the parents for
labeling and reacting to their child behavior and drawing negative
attention to their speech.
Our understanding of stuttering has come a long way
since the Johnsonian days and though the approach to treating
children is now diametrically opposite (i.e., we now advocate direct
intervention), it is still implemented with the assumption that taking
advantage of early neural plasticity is the best recourse for halting
the stuttering pathology. The question is, are the results achieved
nowadays any better? The Lidcombe program provides a parent-
based behavioral, response contingent approach to stuttering. In
this therapy, parents attempt to reduce stuttering by presenting
verbal positive affirmations for fluent speech behaviors and for
reducing " bumpy speech”. The ability of these children to reduce
their stuttering in front of clinicians is not new. Employing parents
as clinicians and collecting data in multiple settings is a new
approach in stuttering therapy and seems the signature of the
Lidcombe program, yet still does not eliminate a potential
Hawthorne effect during data and does not mean that any
observed reduction or elimination of stuttering occurs across
speaking environments and situations. Short-term reduction in
stuttering frequency is easy to demonstrate with any kind of
therapy2, whereas recovery appears to be difficult to achieve in
persistent stutterers at any stage of development.
Lidcombe behavioural therapy has been practiced for
over a decade. Its popularity has spread across the globe. In fact,
specialized manuals and training centers exist to help clinicians
become proficient in implementing Lidcombe procedures. Now, in
this day of "evidence-based" therapy, the first randomized trials by
these authors should be applauded. They took substantial efforts
to ensure that groups were adequately randomized and balanced,
the treatment was administered according to protocol and the
'counting of stuttering' was conducted by observers who were blind
to treatment allocation. However, knowing the natural recovery
rates, we are unsure whether the advantages of employing an
untreated control group outweigh the fact that a potential remedy
was withheld from children during a critical time in the pathological
development. Regardless, the authors suggest that the results
support the 'efficacy' of the Lidcombe program. An important
question in this study is how efficacy is defined. In this case,
efficacy may merely be an acceleration of the natural healing
process in those children prone to recover or a simple temporary
reduction in stuttering that that can occur with any therapeutic
program for incipient stuttering.
For any program to be considered truly effective in the
treatment of incipient stuttering it should be able to 'beat' Mother
Nature and show complete recovery (i.e. forever free from all
stuttering symptoms in most situations and the perception of being
a person who stutters) rates in excess of 74%.3 However, since its
inception, one of the main points of contention with this program,
as well as others that claim efficacy in remedying childhood
stuttering, has been the separation of therapeutic effects from
those of natural 'spontaneous recovery'. In this study, 134 children
were referred for research program but the results are only
reported 47 children, although the other children may have not
meet some research-imposed criteria it would have been very
informative to see the natural progression of the disorder. As a
group these 47 children demonstrate a mild to moderate
pathology, the use of mild to moderate children is typical of this
research group when they show results of less than 1 or 2%
stuttering.4 Results show that after nine months the mean
stuttering frequency in the treatment group was still 1.5%, with only
52% of children showing a stuttering frequency of less than 1%.
Additionally, in an earlier investigation into the impact of Lidcombe
program on early stuttering, the mean stuttering frequency
following a 12 week treatment was 3.5 % syllables stuttered,5
indicating that traces of stuttering were most likely still evident in
many and the pathology may be subject to 'balloon' again at a later
date. These data show no evidence of complete recovery
exceeding 74%. Therefore, this program cannot claim to heal any
child that would not be otherwise remitted if simply left under the
care of Mother Nature. Similarly, Franken et al. (2005)6 compared
the Lidcombe approach to a Demands and Capacities approach
and both treatments yielded similar positive outcomes. We suggest
that almost all therapies can be helpful in alleviating some of the
symptoms of childhood stuttering.7 The simple fact that children
are learning some means of temporarily 'inhibiting' stuttering in
nurturing environments (e.g., with parent therapists) can help ease
the burden of stuttering and train coping mechanisms. For those
who are likely to recover anyway, almost any type of therapeutic
intervention may accelerate the process. Thus, it is doubtful that
the Lidcombe or any other behaviorally based program is powerful
enough to rewire neural networks and alter the epidemiology of
stuttering. Treating children who stutter may be analogous to
attempts to increase adult height by administering human growth
hormone to children who are not growth hormone deficient.
Though short periods of accelerated growth can be observed, the
final height attained is often similar to what matched children
achieve without the hormone treatment.8 In other words,
regardless of therapy, Mother Nature still seems to have the final
word on who recovers and her agenda is not fooled by temporary
periods of accelerated gains.
We are advocates for providing children who stutter with
all the help in the world. Accelerating recovery and providing
stuttering children with means of coping with the pathology
remains a most noble cause. However, when employing the
Lidcombe program and stuttering persists, we must also caution
against falling into the Johnsonian snake pit of blaming parents for
an involuntary childhood pathology whose full recovery is most
likely beyond their control.
References:
1. Johnson W. A study of the onset and development of stuttering.
In Johnson W, Leutenegger RR, eds, Stutttering in Children and
Adults. Minneapolis: University of Minnesota Press, 1955.
2. Bloodtein O. A Handbook on Stuttering. San Diego, CA:
Singular Publishing Group, 1995.
3. Kalinowski J, Saltuklaroglu T, Dayalu V, & Guntupalli VK. Is
it
possible for speech therapy to improve upon natural recovery
rates in children who stutter?. Int J Lang Comm Disord
2005;40:349-58.
4. Onslow M, Andrews C, Lincoln M. A control/experimental trial of
an operant treatment for early stuttering. J Speech Hear Res
1994;37:1244-59.
5. Harris V, Onslow M, Packman A, Harrison E, Menzies R. An
experimental investigation of the impact of the Lidcombe Program
on early stuttering. J Fluency Disord 2002;27:203-14.
6. Franken MC, Schalk CJ, Boelens H. Experimental treatment of
early stuttering: A preliminary study. J Fluency Disord, doi:10.1016/
j.jfludis.2005.05.002.
7. Kalinowski J, Dayalu VN, Saltuklaroglu, T. Cautionary notes on
interpreting the efficacy of treatment programs for children who
stutter. Int J Lang Comm Disord 2002;37:359-61.
8. Kawai M, Momoi T, Yorifuji T, Yamanaka C, Sasaki H, Furusho
K. Unfavorable effects of growth hormone therapy on the final
height of boys with short stature not caused by growth hormone
deficiency. J Pediatr 1997;130:205-09.
Joseph Kalinowski, PhD
kalinowskij@mail.ecu.edu
http://www.ecu.edu/cs-dhs/csd/stutt.cfm
Competing interests:
None declared
Competing interests: No competing interests