JCPSLP Vol 19 No 2 2017

Rolling-group delivery model supports sustainable intervention Rolling-group intervention delivery is a model of care unfamiliar to paediatric SLPs, though often used in the field of psychology (Bauld, Ferguson, McEwen, & Hiscock, 2012; Tasca et al., 2010). Arnott et al. (2014) explained that such groups begin with a set number of child–parent pairs and participants change over time. As a child–parent pair completes active treatment (little or no stuttering), they are replaced by a new child–parent pair. This rolling process creates a group where novice and expert child–parent pairs are simultaneously being treated according to the LP guidelines but at differing levels. A single RCT has recently reported on the rolling-group delivery of the LP (Arnott et al., 2014) with successful results. Fifty-four child–parent pairs were randomised into either a control arm (individual) or treatment arm (rolling-group). There were no statistical or clinical differences noted between the arms with regards to number of clinical visits or weeks in treatment. Of great significance to SLPs was the fact that the rolling-group arm consumed 46% fewer clinical hours per child to the completion of Stage 1 (little or no stuttering). Where community-based SLPs are struggling to provide equitable treatment for this population, particularly in rural communities (Verdon, Wilson, Smith-Tamaray, & McAllister, 2011; Wilson, Lincoln, & Onslow, 2002), this unfamiliar model may provide a sustainable alternative to traditional individual treatment. While considered “gold standard” research, a single RCT may represent only a partial picture of treatment effectiveness (de Sonneville-Koedoot et al., 2015; Ioannidis, 2005), whereas a Phase IV community-based trial, independent from program designers, offers a “real-world” assessment (Onslow, 2016). In their community-based study, O’Brian et al. (2013) highlighted that “efficacy” studies, with their stringent criteria and protocols operate differently from “effectiveness” translational studies which investigate how a treatment stands up within the community for which it was designed. Clients drawn from a single site, with only two treating SLPs and strict criteria for inclusion were limitations cited by Arnott et al. (2014) of their RCT for group LP treatment. Therefore, the aim of this translational study was to determine if SLPs could produce clinically equivalent reductions in stuttering severity for young children when delivering the LP in a novel rolling- group model within their community-based settings. The qualitative portion of the study examining the perceptions of the participating SLPs regarding the viability of the rolling-group model for future service delivery is presented in Rappell and Schmidt (2017) and a report incorporating both portions of the study has previously been completed Approval to conduct the study was obtained from the North Coast NSW Human Research Ethics Committee (Ref. LNR 073). Participants and setting Participants were 19 children aged 2 years 9 months to 6 years and their parents who approached speech pathology services at a designated centre for advice regarding, and/or treatment of, stuttering. Children diagnosed with a major neurological disorder, such as attention deficit hyperactivity disorder, autistic (Rappell, 2015). Methods

spectrum disorder, or Tourette syndrome, that may make the assessment of unambiguous stuttering difficult were excluded. Participating children did not undergo a full developmental assessment, as such minor developmental, emotional, communication or neurological impairments may have been concomitant with their stuttering. Six SLPs from six community health centres volunteered to undertake the training and instigate a LP rolling-group. Formal training by Lidcombe Program Trainers Consortium (LPTC) for individual treatment and/or direct training from the program developer Mark Onlsow as part of undergraduate degree studies was the only stipulated requirement. Participating SLPs had from 8 years to over 35 years clinical experience. Rolling-groups were established at differing times across four community health centres, between March 2014 and April 2015, led by a single SLP located at each of the sites. Parent training session Before the commencement of the LP rolling-group, each child–parent pair was offered a single individual session. This 60-minute session provided information on early skills and knowledge that would be required in treatment. Parents were introduced to the 10-point LP Severity rating (SR) scale and the child’s stuttering severity was recorded by the SLP. Rolling-group format This study followed the guidelines in The Lidcombe Program of Early Stuttering Intervention Treatment Manual (Packman et al., 2011). Each group consisted of between two to four child–parent pairs. While Arnott et al. (2014) aimed to maintain group composition of three child–parent pairs, these ultimately ranged from one through to four. In response, the present study was designed to accommodate a range from two to four child–parent pairs at group commencement, with consideration to the variability of client intake numbers across the study sites. Initially, the groups comprised solely of children starting their treatment. However, as one child–parent pair reached criteria to Stage 2, it was replaced by another pair. Weekly groups were between 45 and 60 minutes and were led by a single SLP. The rolling-group used an area which allowed for “activity stations” and a main area where the SLP could engage in a whole-group activity. While each group consisted of the core LP elements as used within standard individual treatment, variation did occur within the treatment sequence. Children often had an active role in determining the treatment sequence through how they interacted with the “activity stations” upon entry into the room. For instance, it was determined that should children wish to engage in free-play, the session may begin with rating and adult problem-solving, whereas children choosing to sit for a table-top activity might lead to a SLP or parent demonstration of treatment. Data collection and analysis The children’s stuttering severity was assessed at four points: (a) Pre–treatment assessment; (b) the completion of Stage 1; (c) 6 months post-commencement; and (d) 9 months post-commencement. At each point a stuttering severity rating (SR) and percentage syllable stuttered (%SS) were calculated within clinic, during the group closest to that date. Both SR and %SS were assessed by the treating clinician and while no formal analysis of inter-observer reliability was undertaken, all six participating SLPs and two stuttering specialist SLPs were sent a video containing a

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JCPSLP Volume 19, Number 2 2017

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