Contents. Pages 1-2 Lidcombe Link Days and Courses. Pages 3-6 Case Study 1 by Kate Morley. Pages 7-8 Sue O Brian s Problem Solving Checklist

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1 It seems fitting that we have a snowy look to this edition of the Lidcombe News after the winter we ve been having here in Northern Europe! A warm and happy new year to you all! We also have a change of theme from the last few editions which have concentrated on reporting research into the Lidcombe Program from around the world. The next few editions will have a more clinical theme with case studies focusing on the sorts of decisions and problem solving that takes place in our daily practice, as well as some practical help in the form of a checklist from Sue O Brian from the Australian Stuttering Research Centre. This is all in addition to the usual news of courses and Link Days, and our ever popular Dear Sue and Can You Explain That Again from the Stuttering Unit in Bankstown, in Sydney, Australia. DATES FOR YOUR DIARY The next Link day for the Northwest is on Tuesday 16 th March 2010, 1:00 for 1:30 at North Huyton PCRC (Woolfall Heath Avenue, Huyton L36 3TN opposite the PDSA vets). Bring any cases you want to discuss. For further details contact Helen Wilson on tel or by helen.wilson@knowsley.nhs.uk Central England is holding its next Link day on Monday 14 th July 2010 from pm at Coventry + Warwickshire Hospital, Stoney Stanton Road, Coventry CV1 4FH. The day will focus on developing information and advice sheets, discussing the benefits of setting up a Yahoo group, the place of the LP on care pathways, sharing resources and rewards, and a discussion on the LP article in IJLCD 43 pgs Contact Debbie Middleton on tel or Debbie.Middleton@coventrypct.nhs.uk for further details if required. Contents Pages 1-2 Lidcombe Link Days and Courses Pages 3-6 Case Study 1 by Kate Morley Pages 7-8 Sue O Brian s Problem Solving Checklist Pages 9-10 Dear Sue Pages Just Explain That Again.. Pages Case Study 2 by Lizzie Hunt Norwich is holding its next Link day on Tuesday, 7 th September, 2010 from 9-3 at 40, Upton Road. Bring/buy your own lunch. Contact Sally Lelievre for details, directions etc. on tel , or Mary Kingston on: kingstonamee@talk21.com Contributions to Mary Kingston. Send your ideas and questions to: kingstonamee@talk21.com I can't promise to include everything and have to reserve the right to edit contributions as necessary. But I'll do my best! 1

2 COURSES AND EVENTS It has been agreed by the Lidcombe Program Trainers Consortium that the two day workshop (three days in countries where English is not the first language) is only for Speech and Language Therapists (Speech Pathologists etc) who have graduated. It is not designed for parents ( unless thay are qualified SLTs), students, TIs or members of other professions e.g. psychologists, doctors, teachers etc. I have removed the courses which I know to be full. This includes the Belfast course advertised in the last edition. There are several other workshops being run around Europe but as I have heard that these are also full they do not appear below. The annual London course will be running on Tuesday and Wednesday, March 16 th & 17 th 2010 at the Royal College of Speech and Language Therapists. Contact Sally Wynne on lidcombe@live.co.uk or Mary Kingston on kingstonamee@talk21.com for the flyer and booking form. Oxford is holding a workshop on Monday and Tuesday, May 24 th & 25th 2010.This will take place at Warneford Hospital. The course is being led by Rosemarie Hayhow and Polly Mitchell. For further details contact Polly Mitchell on pmitchell224@googl .com There will be a further course in London in the autumn. It will be held on Monday and Tuesday October 4 th & 5th 2010 at the Royal College of Speech and Language Therapists. Contact Sally Wynne on lidcombe@live.co.uk or Mary Kingston on kingstonamee@talk21.com for the flyer and booking form. The rest of this edition of Lidcombe News is dedicated to problem solving and the decisions we make during the therapy process with the Lidcombe Program. Two therapists each take us through one real life case ( all names changed) to show us what sorts of decisions they had to make and the difficulties that arose during the therapy process together with the solutions they and the parents worked out together. Empowering of parents (and indeed of the children too) underpins the Lidcombe Program and the following case studies show how this process develops as therapy progresses. We also have an updated checklist of troubleshooting questions designed by Sue O Brian of the Australian Stuttering Research Centre, when she came over to the United Kingdom in January 1998 to deliver the first Lidcombe Program workshop in Europe. Sue O Brian is the original Dear Sue of this Newsletter and we are grateful to her for allowing us to publish this checklist which has, I know, often been taken out and perused in our clinics since she first gave it to us! 2

3 Problem solving is a key element of the Lidcombe Programme; parent and therapist working together to find creative solutions to negotiate the twists and turns of the treatment process. Kate Morley, a speech and language therapist specialising in dysfluency and working for NHS Norfolk in the Norwich Specialist Dysfluency Clinic for children and adults takes us through a recent case. Initial assessment of Lucy s stammer by her community speech and language therapist gave her a severity rating of 8. She presented with a severe stammer and a fairly typical pattern of sudden onset at around age 3. In addition there was a family history, with her paternal grandfather also stuttering throughout childhood but who subsequently recovered. At our first appointment in the Specialist Clinic Lucy presented as a quiet child who was reluctant to say much, though this was to change! Syllable repetitions, prolongations and mild blocks were evident in clinic and these were confirmed as representative of her speech at home by her mother, Karen. Lucy showed signs of frustration; sighing and giving up half-way through a conversation. Her parents had noticed facial tension accompanying more severe stutters and were concerned that Lucy would stop talking during more severe patches and that she was becoming less confident. They were understandably keen to begin treatment. We started the Lidcombe Programme just a few weeks later when Lucy was 4 years 4 months, with school just a six months away. Her parents were anxious that she should be speaking more fluently by then. Her %SS was 4.8 at our first session, though this did not reflect her home SR scores. After some discussion and demonstration Karen had her first go with therapy. Structuring her language to support Lucy s fluency took some practice because, from the start, Lucy was keen to take the lead in their conversations. Taking on a more directive role to structure the language and activity for treatment was a new experience, both for child and parent, and presented our first problem. Problem: Karen was used to allowing Lucy to take the lead and direct activities, and structuring Lucy s language and taking control of the activities for the 20 minutes or so of session was foreign to her. I demonstrated how, by anticipating Lucy s responses and matching her enthusiasm, I was able to shape the interchange without spoiling the pace and interaction of the conversation. By using turn taking activities and language that elicited simple responses, it was possible to restrict her language to short, fluent phrases which I could praise. Karen was very concerned and unsure that she would be able to work with Lucy in this way. Together we practised in the clinic and I offered her support and encouragement. But it was something we had to discuss and try again and again because understandably it wasn t her natural style of interaction with her daughter. Lucy however was accepting of 3

4 it once she got used to it and as it was only for about 20 minutes or so per day they managed eventually to work it out. A handout giving concrete examples of ways to elicit single words and short phrases (naming pictures, describing objects, giving choices, using opposites, etc) was also helpful to her in these early stages. Learning to give contingencies and even managing tangible rewards with a child used to taking the lead stretched multi-tasking skills to the limit in the early stages of learning how to carry out treatment. However once Lucy s mother became confident that she was able to structure the activities and Lucy s language, she managed to give the contingencies appropriately. Lucy was now becoming consistently fluent in treatment up to 4-word phrases, fixing bumps happily and although not outwardly enthusiastic about the praise, she was accepting it well. Lucy s attention flagged easily and by week 4 Karen was finding it difficult to keep the sessions fun. The novelty of smooth talking was beginning to wear thin and Mum felt treatment at home was becoming less enjoyable. Problem: Sessions started to become less fun. Karen felt Lucy responded better to toys than books although she was concerned that this would be even more challenging in the treatment times as Lucy would get more involved in the play materials and less receptive to the contingencies. We therefore chose play activities which allowed for greater structure such as Mr Potato Head, duplo sets (e.g. a farm) and used them in a way that allowed Karen to be in charge of the pieces. She kept them in the box and Lucy chose them one by one. By week 5 Karen was getting to grips with managing treatment through play. Re-assured that if she felt a session hadn t gone so well, she could do a second with a book later in the day, our problem was resolved. The key factor was for Lucy to enjoy treatment. Lucy s SRs remained variable for the first 9 weeks, a mixture of 4s and 5s and occasional 6s, but I was not surprised, because the early weeks had been about focusing on Karen developing the skills required to carry out structuring treatment effectively, as described above. Decision point By week 10, we started to see results with a few SRs of 3 appearing and a Within Clinic (WC) score of 3%SS. With the lower SRs, we introduced unstructured feedback for stutter-free speech. Unfortunately at this point we were unable to meet for a month because of the summer holidays and without the routine of weekly support Lucy s mother was unable to sustain focus on therapy. The scores went back up to 5s and 6s 4

5 during this time but just as were getting back on track Lucy contracted swine flu and then started school for the first time. With hindsight, I realise we could have discussed in more detail how she would manage the change of routine over the summer holidays, with other children at home, going on outings and so on, to allow her to sustain the progress we had just been beginning to see. Problem: sustaining therapy over an enforced break from clinic visits. More detailed discussion around the likely barriers to focused therapy which could arise when the family was busy and on school holidays, when other siblings were around, and how Karen felt she would be able to overcome them, would have been useful. Problem solving in advance around issues such as time management in a busy family, and increasing the structure in therapy to manage higher levels of stuttering should they arise, would have prevented an over reliance on contingencies in unstructured situations when this was not always appropriate. Such a discussion would have helped with Karen s own problem solving as the difficulties arose. Interestingly neither the swine flu nor the experience of starting school for the first time impeded Lucy s progress. As the home routine returned to normal, Karen s focus on therapy returned, SRs dropped back to 3s and 4s, Lucy had a WC score of 2.2% SS, and then by Week 15, the first 2s appeared. Decision point: reduce structured sessions, increase reliance on contingencies in unstructured situations. Karen was now giving contingencies in unstructured situations (about 30/day) but there were still occasions during the week when they would do more focused play sessions, during which time she was giving more intensive contingencies. At one clinic visit, Karen reported that Lucy had said: You stop me playing during one of these sessions. Problem: Karen was keeping more control over play activities than was required at this stage in therapy. Once she had learned a new skill it was difficult for her to adapt to changing circumstances. Interestingly Lucy had tolerated this control in the early stages but now that stutter free speech was so much easier for her she could sense it wasn t required. I demonstrated again how it was possible now for Lucy to play in her own natural way while I dropped in the contingencies at intervals, without stopping the flow of the conversation. Karen practised this as well, and she also discovered that using acknowledgement more than praise helped in these situations. We then discussed how there was now no longer a need for her to take control of the 5

6 activities as had been the case in the initial stages of treatment and that she could now relax back to her original style whilst still giving the contingencies. We were now very close to stage 2 and were awaiting 3 weeks of more 1s than 2s and below 1%SS in clinic to enable us to do this. At this point however the family had to move out of their home because they had started a large building project. They were now living with Karen s parents which made for occasional difficult changes in the normal family routine and behaviour. Interestingly this did not affect Lucy s Severity Ratings, but Karen was concerned that with the changes in family life she wasn t always able to remember or to fit in the required number of contingencies each day. Also, Lucy s grandmother was puzzled as to why her daughter was still giving Lucy feedback when she was so obviously fluent; comments which affected Karen s ease with giving the contingencies. Problem: remembering to give contingencies in unstructured situations and dealing with family comments. We dealt with the first part of this by going through Karen s day looking at times when she and Lucy were together and when it was appropriate to give contingencies e.g. on the longer drive to school and back each day, in the bath, making Lucy s packed lunch for school together etc. Putting up post-it notes in the kitchen and in the car to remind herself to give contingencies was also helpful. While it was understandable that Lucy s grandmother was surprised that Lucy was still receiving contingencies when she was so fluent, we went through why it would not be helpful suddenly to remove or reduce them. Karen could then explain to her mother about the possibility of relapse if she stopped the treatment in this way. I then explained how during the second stage of the programme (Stage 2) we would start withdrawing them but in a careful and systematic way. Decision point: when to go to Stage 2 Lucy went onto Stage 2 after Christmas (we could have gone earlier but Karen was worried that Christmas would make the scores go up) so it was left until the first week of the new year before we did this. In fact it would have been safe to have started Stage 2 earlier as Lucy did maintain SRs of more 1s than 2s over the Christmas period. With these extra three weeks Stage 1 took 26 weeks and since starting Stage 2 all continues to go well. 6

7 Sue O Brian s Problem Solving Chart- first developed in 1998, later updated to take account of the new terminology. Troubleshooting Checklist of questions to ask yourself Therapeutic technique Has period of stutter-free speech ever been established? Getting started with a severe stutter? Are branching steps necessary? Can child self-evaluate? Treatment/ Feedback Is treatment being done effectively at home? Is treatment being done consistently at home? Is treatment being done frequently enough at home? Is the structure being varied according to stuttering severity? Is parent able to give sufficient time to therapy? Is parent able to give sufficient concentration to therapy? Is child enjoying treatment? Is time/place/situation of treatment being varied? Is balance between structured and unstructured therapy appropriate? Is this person the most appropriate one to be giving treatment? Is parent still maintaining +ve feedback into Stage II? Is feedback appropriate/genuine? Is feedback too vague? Is feedback too negative/positive? Is feedback immediate? Is feedback consistent? Is feedback frequent enough/too frequent? Is parent comfortable with negative feedback? Does feedback suit parental style? Are too many/not enough people giving feedback? Is feedback acceptable to the child? Is parent able to identify stuttering accurately? Has feedback been withdrawn too quickly? Rewards/reinforcement Is reinforcement appropriate for age and stage of therapy? Is there overuse of reward? When are rewards being given (if at all)? Is reward distracting from therapy? Has behaviour to be rewarded been clearly defined? 7

8 Data collection Has data been collected? Does parent understand rationale behind data collection? Is amount/type of data collection appropriate for this family? Is data accurate? Is data representative of beyond clinic situation? Is parent able to interpret data usefully? Is covert data collection necessary? Stage II/Relapse Has this begun before the child/parent is ready? Has parent stopped giving feedback? Is parent only giving negative feedback? Has treatment been withdrawn too quickly? Is parent aware of how to respond to relapse? Has child ceased to self-evaluate? Has relapse been responded to immediately? Has parent assumed clinical role? Has parent been encouraged to contact clinician immediately for help? Family dynamics/expectations Who works best with the child? Nature of the parent/child relationship? Who attends treatment compared with who administers treatment at home? Sibling interference? Are treatment demands realistic for this family? Is the parent comfortable with the treatment? Is the parent comfortable with asking for self -correction? Does parent understand concepts or only procedures? Is parent able to problem-solve? Can parent accurately identify stuttering? Is a parent a person who stutters? Motivation All of the above lead to positive therapy environment Expectations of therapy? 8

9 Dear Sue Masha is a child of 4 years old who does not speak any English though I can hear when she is speaking to her mother that she has a severity rating of around 6. I have spoken at length to her mother who has perfect English, and who has read a great deal about the Lidcombe Program on the internet and has a good grasp of its principles. She is very keen for Masha to try the programme and I feel that it would suit this family very well. I am however wondering about the best way to proceed! The two areas that most concern me are demonstrating therapy and then watching Masha s mother carrying out the treatment as she would have to do this in Russian. Then of course there is the measuring of the %SS, though I think I could teach the parent to do this. I would be very grateful if you could give me some ideas to help me problem solve this case, or do you, in your experience, think the obstacles are too great for Masha to try the Lidcombe Program? I agree that a trial of the Lidcombe Program would be appropriate although there are several obstacles as you suggest. As far as I am aware there is not any literature about this type of situation and it would be important to be up front about that with Masha s mother. One of the implications is that the published norms for the Lidcombe Program may not be relevant in this case. It would be important to start the therapy process by spending time with the mother identifying Masha s stutters and assigning severity ratings to speech samples to ensure that both you and the mother are accurately identifying stuttered speech. According to Van Borsel, et al. (2005) speech pathologists who are experienced in the field of stuttering can assess stuttering in a foreign language but should also call upon the help of a trained native speaker to support their assessments. In this case, Masha s mother could be the native speaker that you confer with. Severity ratings are used for all Lidcombe Program cases and it is good to know that O Brian et al. (2004) have reported that severity ratings are a reliable measure of stuttering. Ideally you will be able to use %SS and severity ratings as both of these measures are cited in the Lidcombe Program manual. If for some reason the %SS measure is not able to be used then severity ratings may suffice. When you are satisfied that you and the mother are in agreement about stuttered and stutter-free 9

10 speech, then it would be appropriate to start training the mother to do therapy. In relation to demonstrating and watching the mother carry out therapy, I would suggest that it is not possible to demonstrate the therapy since Masha does not speak English. Instead I would advise you to provide a detailed description of the therapy to Masha s mother. This would need to include how to structure the therapy activity so that Masha is able to achieve effortless stutter-free speech, and also how to give verbal contingencies. It would be a good idea to start with praise for stutterfree speech only, until you are comfortable that the mother is doing therapy appropriately. As with all Lidcombe Program cases you will continually need to evaluate the treatment and its impact. If progress is not occurring or the child is not enjoying therapy, you should problem solve with Masha s mother. You may consider having an interpreter present. I have done this and the interpreter and I watched through an observation window. The interpreter was able to tell me what the parent and child were saying without distracting them. Another helpful strategy may be to ask the parent or an interpreter to tell you some key words that would be praise for stutter-free speech and correction for stutters so that you can listen for those phrases. This can assist in assuring that the parent is using sufficient praise and not too much correction. It is also important to watch the child s response to therapy. They should be enjoying therapy and you should observe them talking with effortless stutter-free speech. References: Van Borsel, J. & Medeiros de Britto Pereira, M. (2005). Assessment of stuttering in a familiar versus an unfamiliar language. Journal of Fluency Disorders, 30, O Brian, S., Packman, A., Onslow, M. (2004). Self-Rating of Stuttering as a Clinical Tool. American Journal of Speech Language Pathology, 13,

11 Do you have students in your clinics? If so, do you have tips about how to get them involved in the therapy process? Would you recommend that they attend an LPTC workshop on top of this once they become qualified? Yes we do have students attend our clinic from time to time. The clinic I work for is considered to be a specialist clinic and clients attend with the understanding that they will be seen by a specialist clinician. For this reason we are very cautious about the level of involvement that a student has. Initially the student would share the client with me as the specialist clinician. As their placement progresses and I feel confident with their level of knowledge and skill, I may let them lead sections of sessions. I would not allow a student to interact with a client without direct supervision.in the state that I work in students are only given preliminary training in stuttering at university. I would therefore strongly recommend that any clinician working with children who stutter attend an LPTC workshop, including those who have had a placement with me. Observation and clinical placements do not take the place of training in the Lidcombe Program. It is often cited that the mean number of sessions to Stage II is 13 ( used to be 11, see LN ed 34 for reasons for this change). Are there other benchmarks in therapy that we could be following e.g. for time taken to see a drop in the Severity Ratings Here is a summary of papers related to this question followed by some comments:- Is treatment taking too long? What the research says: Jones et al, 2000 Higher severity at the start of treatment is a predictor of longer treatment time Median of 11 visits to complete Stage 1, ie. 50%of children completed Stage 1 in 11 visits, other 50% took longer 90% complete stage 1 by 22 visits HOWEVER, very large range of treatment times 11

12 Kingston et al, 2003 Median of 11 clinic visits to complete Stage 1, ie. 50%of children completed Stage 1 in 11 visits, other 50% took longer It should be noted that the above medium time to complete Stage 1 was prior to the stipulation in the manual that criteria for entering Stage 2 be achieved across 3 consecutive visits. Rousseau et al, 2007 Median of 16 visits to complete Stage 1 The authors comment that in light of the LP manual stipulation that 3 consecutive visits meet criteria prior to entering Stage 2, clinicians could expect the following: o Severity ratings of 1-2 and below 1%SS could be expected in a median of clinic visits with Stage 2 being achieved after another 3-5 visits. Another benchmark that we use to assess treatment progress is from a publication by Onlow et. al. (2002) in which they found approximately a 30% drop in severity ratings during the first 4 weeks of treatment (by clinic visit 5). You should look for early trends in severity ratings indicating a reduction in stuttering severity. If progress is not evident then I would recommend reviewing the Lidcombe Program components to ensure that you understand why this is the case. As always, work with the parent to problem solve any issues that may be holding up progress. References: Jones, M., Onslow, M., Harrison, E. and Packman, A., 2000, Treating stuttering in young children: Predicting treatment time in the Lidcombe Program. Journal of Speech Language and Hearing Research, 43, Kingston, M., Huber, A., Onslow, M., Jones, M., & Packman, A. (2003). Predicting treatment time with the Lidcombe Program: Replication and meta-analysis. International Journal of Language & Communication Disorders, 38, Onslow, M., Harrison, E., Jones, M., Packman, A. (2002). Beyond-clinic speech measures during the Lidcombe Program of Early Stuttering Intervention. Acquiring Knowledge in speech, language and hearing. Volume 4, Number 2, Rousseau, I., Packman, A., Onslow, M., Harrison, L., & Jones, M. (2007). An investigation of language and phonological development and the responsiveness of preschool age children to the Lidcombe Program. Journal of Communication Disorders, 40, Dear Sue and Just explain that again... come with our very grateful thanks from Stacey Sheedy and Verity MacMillan of the Bankstown Stuttering Unit in Sydney, Australia. 12

13 Lizzie Hunt has been a Specialist in Dysfluency, using mainly the Lidcombe approach, for about 10 years. She works in Cambridgeshire and is a Team Leader in the community service there. She regularly attends the Norwich Link Days, and especially enjoys the creative problem solving that Lidcombe therapy requires. Peter was referred to our service at 4 years 6 months by his mother and class teacher early in his reception year. He was assessed a few weeks later by the community therapists (a joint appointment with 2 newly-qualified members of staff), who took a case history and gave advice. Significant factors were: Peter had had recurrent ear infections with associated reduced hearing, and several allergies. It was felt that when the ear infections stopped at around 3 years, his language developed very rapidly from single words to sentences, and this was when the stutter became evident A history of dysfluency on his mother, Linda s, side her sister and father are non-recovered stutterers, and the sister is also partially deaf The stutter had been evident for about 18 months (episodic but not decreasing in severity) Other issues his mother felt to be significant were: Peter is described as a perfectionist he can become very anxious, and has nightmares He is also described as a fidget, which is worse when he is stuttering, and he loses eye-contact; he finds it difficult to wait for anything, including his turn in conversations! The community therapists filled in the Stuttering Assessment Checklist (courtesy of Norwich SLT Department!), recording that the stutter was characterised by WWR, PWR and prolongations, as well as frequent repetitions of initial phonemes. His speech and language skills were otherwise good, and he would become frustrated and give up when he could not get a word out. During the assessment session, Peter showed good social skills and was keen to interact with the therapists and participate in all activities. Dysfluency was noted throughout the session, and the therapists gave an informal severity rating of 7; Linda said this was a good day. She was given advice leaflets about how to support Peter with his stutter, and invited to a further appointment in 4 weeks time. At the next appointment, Linda reported that she had been trying to carry out the advice, particularly slowing down her own speech, but that Peter s speech seemed to have got worse. (Incidentally, she made an interesting point: as a teacher, she queried whether the Reading Scheme Peter s school uses could be reinforcing the stammer by emphasising the initial phoneme, and encouraging repetition of a sound.) 13

14 During the session, the therapists observed similar speech behaviours to the previous session, and discussed referral for Lidcombe therapy. Linda was very happy for this referral to take place. Decision point- Lidcombe Therapy recommended. I met Peter with his mother and younger brother 3 months later; she reported very little change and was evidently very concerned. I obtained a sample of speech from his free play and Peter s %SS was 4.1, with several repetitions of initial sound, part-words, whole words and phrases, and some prolongations of vowels and consonants; there were no complete blocks, and he maintained the flow of his utterances with good eye-contact. We agreed upon a Severity Rating of 6. We then talked through the Lidcombe programme and I demonstrated a one-word level therapy session with a book (Peter could manage 1WL nouns smoothly, but needed a pronoun cue for verbs). Linda was easily able to understand the rationale for this approach and was very competent when carrying out the session herself. They left the session seeming much more positive and ready to start the programme. The next week there was good news. Although the home Severity Ratings were still 5s to 7s, Peter had enjoyed the therapy sessions, and both nouns and verbs were completely smooth, with or without cues. They had also set up a brilliant sticker chart with different cartoon characters praising Peter s speech! We played with an alphabet toy for the speech sample and his %SS was 2.0. He was really interested in the concept of smooth talking had even been experimenting with different ways of saying words - and when I mentioned the word bumpy in the therapy session, he could immediately make it smooth and was thrilled to know how to fix a bump! He was very motivated by stacking bricks as he said smooth words, but was impatient to read the story. Problem: Peter was impatient to know what the story was about which meant he lost some focus on his speech: Linda and I agreed this might be solved by looking through the whole book first before starting a therapy session, so that Peter could stay focused more easily when practising smooth words and fixing bumpy words. By the third week the home SRs were between 4s and 6s and Linda reported a general overall improvement. A sample of his speech taken while playing with Duplo in the clinic gave 1.1 %SS. Peter had continued to enjoy the therapy sessions and the sticker chart, and was now spontaneously evaluating stuttered words and fixing them with pride! However Linda told me that she concerned that he was getting tired after a day at school, and then having a therapy session as well as school homework. 14

15 Problem: therapy and school homework were making Peter tired. Linda did not want him to lose interest in the therapy because of this conflict..she also felt that the therapy was the more important at this stage in his life. Linda solved this herself by going to see the class teacher and discussing the problem with her. The teacher agreed he could stop having homework tasks from school so that they could concentrate on the therapy sessions. By now in the therapy session Peter was managing long smooth utterances, though still needing some structure. We then had a two-week break over Easter, and there was more good news. SRs were down to 3s and 2s, and relatives were staggered by Peter s speech. The repetitions were now nearly all whole words or phrases, usually when gaining attention (e.g. mummy-mummy-mummy). Peter was still loving the therapy sessions and reward charts, consciously fixing bumps when he wanted to, and I heard only slight repetitions of and in his free play. He was a little less fluent when I asked him to tell me about his holidays. Decision point: reducing structured therapy, introducing less structured treatment I decided that we should begin reducing the structure of sessions at home, and using Mary Kingston s flower-press analogy including context, content and linguistic complexity, I explained how we could go about this and demonstrated it within the clinic.. Over the next few weeks, ratings stayed around 2 with several 1s and almost no stuttering was heard during therapy appointments. There were occasions when Peter was trying to express complex ideas when he would use er and and more frequently, but this seemed to be related more to planning and revision than to a recurrence of the stammer. Decision point: move to Stage 2 When there had been more 1s than 2s for 3 weeks, we moved to Stage 2 of the programme and began to progress through the schedule. This continued until the beginning of the autumn term. Then Peter had some upsets at school and his hearing was very low because of ear infections and recurrence of glue ear. Severity ratings increased from 2s/1s to 2s/3s. Problem: increase in severity ratings and %SS in Stage 2 because of some school upsets and health issues. 15

16 We discussed what had helped Peter initially and agreed to reintroduce some structured treatment sessions with lots of positive verbal contingencies. We also reintroduced the sticker charts that he loved so much. This brought the ratings down to mainly 1s again, and by December Peter had been stutter-free for several weeks despite the Christmas excitements. When Mary asked me to submit an article for the News, I decided to use this case because I think there are some interesting issues to consider. Firstly, I think Peter was at just the right age and stage to enjoy the therapy, and to be interested in experimenting with his speech. I know this is not a necessary factor, but I have generally found therapy easier when a child understands the concept of smooth/bumpy in relation to talking. Certainly his progress supports research which suggests that waiting some months for therapy does not reduce the likelihood of successful outcomes. (Reference: Kingston, M., Huber, A., Onslow, M., Jones, M., & Packman, A. (2003). Predicting treatment time with the Lidcombe Program: Replication and meta-analysis. International Journal of Language & Communication Disorders, 38, ) Secondly, Peter s mum was completely committed to the programme: she carried out my advice to the letter and really grasped how to keep the therapy sessions effective and fun; perhaps being a teacher herself helped, and it certainly gave her the confidence to discuss a break from school homework. Thirdly, the therapy was successful despite the presence of several risk factors such as family history. There were also lots of issues going on at home and school and in their lives generally, so that at times mum admitted they had not been able to carry out therapy everyday. This challenged my excuses approach but reminded me to stay confident in and focused on working systematically through the programme, ensuring that the parents know exactly what to do. 16