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Shaping innovative services: Reflecting on current and future practice
76
JCPSLP
Volume 19, Number 2 2017
Journal of Clinical Practice in Speech-Language Pathology
Nicole Rappell
(top), David
Schmidt (centre)
and Margaret
Rolfe
THIS ARTICLE
HAS BEEN
PEER-
REVIEWED
KEYWORDS
CHILDREN
COMMUNITY
HEALTH
LIDCOMBE
PROGRAM
ROLLING-GROUP
DELIVERY
STUTTERING
& Onslow, 2009; Mulcahy, Hennessey, Beilby, & Byrnes,
2008). Stuttering is now considered to be less tractable
as a child ages, with treatment effect sizes reducing from
preschool to adulthood (Onslow, 2016).
Several randomised control trials (RCT) support the
premise that Lidcombe Program (LP) is efficacious and
can lead to a greater reduction in stuttering severity than
would be expected by natural recovery (Arnott et al., 2014;
de Sonneville-Koedoot, Stolk, Rietveld, & Franken, 2015;
Jones et al., 2005). Yet, while efficacious, the LP is known
to consume many clinical hours requiring a median of 16
one-hour clinical sessions followed by 10 one-hour clinical
maintenance sessions (Packman et al., 2015). Community-
based clinicians are faced with numerous pragmatic
dilemmas, particularly pertaining to LP program fidelity
and “dosage”. One such issue is that of the clinical hours
required by the LP, as treatment runs continuously until a
child has achieved little or no stuttering, whereas with most
other impairments, SLPs tend to deliver treatment in cycles
of an active treatment block followed by a no treatment
review period. The LP model of continuous treatment may
add to caseload congestion by significantly increasing the
waiting time of children with other communication issues,
and waiting lists have been cited as a barrier to accessing
SLP services by consumers (O’Callaghan, McAllister, &
Wilson, 2005).
Recommendations pertaining to intervention intensity
or total duration in the field of speech, language and
communication needs vary widely in both timeframe
and specificity. For example Law, Garrett, & Nye (2004)
suggest longer intervention duration (>8 weeks) for
primary developmental speech and language delay/
disorder, while Williams (2012) recommends 30 sessions
of 30 minutes for speech sound disorders. However,
workplace constraints appear to impact on SLPs’ capacity
to implement empirically led recommendations (Baker,
2012). Within private and public clinical practice SLPs are
known to reduce both the session length and the number
of sessions (To, Law, & Cheung, 2012). In their study of the
effectiveness of the LP within Australian community clinics,
O’Brian et al. (2013) found that half of the clinicians reduced
their session length to 30 minutes from the recommended
45–60 minutes sessions and did not habitually have
parents demonstrate treatment within clinic. Alterations
to the treatment guidelines such as these likely speak to
the difficulties SLPs are facing when attempting to follow
evidence-based practice within time-poor clinics.
The rolling-group delivery model for Lidcombe
Program (LP) treatment for early years
stuttering has been shown to be efficacious
in a single randomised control trial, yet few
speech-language pathologists (SLPs) utilise
this option. This paper reports on the
quantitative component of a mixed-methods
study, conducted in 4 rural NSW towns, in
which LP was delivered in a rolling-group
model, by community health-based SLPs.
Nineteen children under 6 years were
recruited. Stuttering severity at
commencement, 6 and 9 months post-
commencement were compared using a
“repeated measures generalised estimating
equation approach”. Stuttering severity
improved significantly in mean percent
syllables stuttered (
p
= 0.001), and mean
parent–clinician agreed severity rating (
p
<
0.001). Mean clinical hours (7.3 hours) and
median number of clinic visits (15 visits) per
child to reach Stage 2 were equal to literature
benchmarks. Our study indicates that the LP
delivered in a rolling-group model by
community-based SLPs who do not
specialise in stuttering is an effective, time-
saving, and viable alternative to individual
treatment.
N
umerous Australian studies have shown the
cumulative incidence of early years stuttering to be
almost double the level previously reported (Reilly
et al., 2013; Reilly et al., 2009; Yairi & Ambrose, 1999).
This rising incidence creates pressure on SLP resources
to provide an equitable, quality service for this population.
Early intervention is considered best practice as children
who stutter have stronger outcomes when treated before 6
years of age (Jones et al., 2005; Onslow, 2016). Judgement
concerning treatment timing has been influenced by
efficacy studies, together with increasing evidence of the
negative sequelae to stuttering for children, adolescents,
and adults (Iverach & Rapee, 2014; Langevin, Packman,
Rolling-group Lidcombe
Program delivery
A prospective cohort study in community health settings
Nicole Rappell, David Schmidt, and Margaret Rolfe