Stuttering Therapy for Preschool-Aged Children

A three-year-old’s birthday cake

Australia leads the world today in the treatment of stuttering in preschool age children. In many countries the procedure is to ignore the early stutter in the hope that it will go away. This was also the trend in Australia until fairly recently. Sometimes the stutter does, indeed, right itself, but it is just as likely to remain and to become worse. An adult who stutters lives under a constant fear of speaking in public; career choices are restricted; depression and social phobia follow in more than sixty percent of cases. Today, however, thanks to a behavioural method devised by a group of academics and clinicians at the University of Sydney, the old approach of ignoring the stutter in young children has been turned on its head with spectacular results.

Professor Mark Onslow of the University of Sydney writes in Chapter Two of The Lidcombe Program of Early Stuttering Intervention: A Clinician’s Guide:

‘The Lidcombe Program is a product of places, people, and times that crossed paths on two continents over three decades. In this short history, I trace those times, people, and places that constitute the history and background of this treatment. In effect, verbal response-contingent stimulation (i.e. drawing attention to the stutter in an appropriate way [author’s note]) as a means to control the stuttering in preschool children found its way from the experimental laboratory of the University of Minnesota into the living rooms of parents of stuttering children (in Australia, Great Britain and the United States) who use the Lidcombe Program today… In essence, that is what the Lidcombe Program is: a clinical model adapted from a scientific laboratory model.’

Matthew Gibson was ten months old when he started to talk. When he was two years old, he was a very good talker for his age. But just short of his third birthday, he was struggling to get a word out.

The day her son started to stutter is etched in Margaret Gibson’s mind forever: ‘It was as if it happened, just out of the blue, from one day to the next,’ she recalls. ‘We were on holiday at the time. He was looking out the window, and he pointed to a bird: “Look there’s a bird at the w…w…w….” He was standing there with his hands over his eyes and he was, like, screaming, but there was no sound coming out. His stuttering came on rapidly from there. It was really, really awful. I wouldn’t wish it on any parent… I was out of my mind with worry, didn’t know what to do, who to turn to.’

Contrary to what was once thought, in about a third of cases, the onset of stuttering is quite rapid, causing this sort of distress to parents.

Stuttering has a long history of being misunderstood and mismanaged.  For many years it had been seen as a psychologically caused complaint. Even in the film The King’s Speech, which documents how an Australian elocutionist assisted King George the Fifth to cope with his stutter, the implication was that it might have been caused by his upbringing; this is today shown to be false.

In fact, a team of researchers at the University of Sydney is leading the world in understanding stuttering and in treating the disorder.

According to Professor Mark Onslow at the Australian Stuttering Research Centre ‘Stuttering is a disorder of neural speech processing, to do with the complexity of moving the many muscles that are necessary for speech.’

It can involve any or all of the following symptoms: repetitions of sounds, words and syllables, prolongations of sounds, periods of silence or “blocks” and twitching of the body and face similar to tics.

Stuttering is a common condition. An authoritative source reports that at any one time, around five percent of people are stuttering. Most of us have known someone who stuttered at school and seen the anguish and humiliation they lived with daily.

Thanks to the Lidcombe Program to treat preschoolers, however, the number of children who stutter at elementary school in Australia appears to this author—once a primary and secondary school teacher—to have greatly diminished.

The situation is not quite as positive for adults who stutter. If not treated in the early stages, stuttering causes all kinds of problems in adolescence, and early and late adulthood. Failure to attain full occupational potential is common, because most demanding jobs require high level verbal communication. And it is now emerging that, not surprisingly, social anxiety is a common symptom of stuttering in adulthood, because many who stutter suffer social phobia, a debilitating anxiety condition linked to a morbid fear of social humiliation.

Watching someone who stutters, stumbling and tripping over words, repeating consonants or syllables, and baulking completely at certain sounds, it is not hard to see why stuttering became associated with emotional disorder or mental illness in people’s minds. And those who stutter were once thought to be “fair game” for comedians and satirists. Who could forget the stuttering Porky Pig? Then there was the buffoon played by Michael Palin in the popular movie A Fish Called Wanda.  This politically incorrect satire of someone with a serious affliction created such a furore in England that Michael Palin, who played the dithering fool with a stutter, subsequently agreed to become the patron of the Michael Palin Centre for Stammering Children (Stuttering is called “stammering” in the United Kingdom). Ironically, however, the psychological model, which tends to link stuttering with psychology or family dynamics, was still common in the UK when Matthew Robinson began to stutter.

Matthew’s parents took him to a speech language therapist (the equivalent of a speech pathologist in Australia) near their hometown, but they were told that nothing could be done for him until he was much older.

“We were very disappointed,” Mary said.

Matthew Robinson was enrolled in nursery school when he began to stutter. ‘He was already getting grief, even then,’ recalls Margaret. ‘The other kids would tease him in the playground: “You’re stupid, you say the…the…the!” That was the worst thing, the teasing he underwent at school. Even though only in kindergarten, he was aware of his disability and was being ridiculed and bullied by the bigger children in the playground.  He didn’t want to go to school, and he became withdrawn. It was heartbreaking. I was ready to try anything that might help him. You can’t imagine our relief when we heard there was a possible solution.’

The teasing had continued and got worse when Matthew started primary school. After three years had elapsed, Margaret and her husband Peter were in no mood to wait any longer. Help came to them from an unexpected quarter—the colonies!

In April 1995, Matthew Robinson’s grandmother read in a magazine about the Lidcombe Program, a radical new approach to stuttering in preschool age children that was being trialled in Sydney with revolutionary success.

Developed by Professor Onslow and colleagues from The University of Sydney, and the Stuttering Unit at Bankstown Health Service, the Lidcombe Program involves hour-long consultations between the speech pathologist, the child and a parent over a period of several months. At the time that Matthew’s grandmother read the article, a preliminary trial had just been run on twelve Sydney children ranging in age from three to five years. Then a scientific paper was published showing that those children continued not to stutter four years later. Evaluations of the Program were published in national and international journals and books.

The procedure is behaviour modification. One of the critical requirements of the treatment is that the child enjoys it, and that the prevailing milieu in which it occurs is parental supportiveness. During the face-to-face sessions, the speech pathologist trains the parent to do the procedure and streamlines it to fit the needs of the child within the family.

The speech pathologist and the parent work directly on the child’s stuttering. Stutter-free speech is praised, and when a child stutters, parents are trained to respond appropriately to their particular child in specific situations: ‘I think I heard a bumpy word then; could you say it again?’ The Program is flexible and sensitive enough to accommodate the wide variations in children’s personalities, their likes and dislikes, and parents’ personal styles. Praise and correction take place in everyday childhood situations. On average, the child’s speech is brought under control in sixteen visits to the speech pathologist. A maintenance program, lasting twelve months, tailored to the child’s individual needs is then drawn up, with the number of appointments decreasing as the child maintains stutter-free speech for longer and longer periods. Despite the apparent simplicity of the treatment, it is very easily mismanaged if not done under the expert supervision of a speech pathologist, who has been properly trained in the technique.

Onslow says ‘There was—and still is in many countries—much suspicion worldwide about behavioural interventions for early stuttering, and academics and clinicians were quite discomforted by the emerging data that showed it to be an effective treatment for preschool children.’

In Denmark Dr Ann Packman, a member of the Lidcombe research team, was told during a conference presentation by a delegate that the Lidcombe Program suppressed the problem “down into the stomach”.

During a tour of the United Kingdom in 1966, the Lidcombe Program team encountered a barrage of criticism from the media and from the Michael Palin Centre. At this time, the British method for treating children who stuttered involved attempts to modify things about the family environment that might be putting pressure on the child. Parents of a stuttering child were counselled in an attempt to fix the underlying problem that might have caused the stutter to arise. Many issues to do with the Lidcombe Program were raised by the media and in professional journals at the time.

It is not surprising that some practitioners in the UK saw the Lidcombe Program as being confrontational. The manager of the Michael Palin Centre in London at the time was quoted as saying in the Telegraph Magazine (27.1.96): ‘Stuttering is a very complicated disorder for this very simplistic approach.’ Some of the responses at the time were very negative and included the charge that it might cause psychological damage to the child.  The Australian team countered this criticism by saying that training for speech pathologists was crucial to the proper outcome of the treatment.

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One evening in his office, Professor Onslow received a telephone call from an extremely distressed Margaret Robinson, relating the terrible problems Matthew was having, and pleading for help. Despite protesting that that there was little he could do do for a stuttering child in England, Margaret persisted to the point at which Professor Onslow’s research team decided to attempt a radical variation of the treatment—to do it by telephone! The Lidcombe Program had never before been attempted without weekly face-to-face contact between the family and the clinician.  However, the research team decided that Elisabeth Harrison, one of the Lidcombe research team would attempt this “distance intervention”.  ‘Surely,’ according to Onslow, ‘this would be the ultimate demonstration that stuttering can be managed effectively without the need for counselling psychology, if the child and parent did not even need to be in the clinic room!’

When Elisabeth first listened to a tape of Matthew’s speech, he was measured at 18 percent of syllables stuttered. On a score out of ten, she gave it a severity rating of eight, which means that his stutter was severe. ‘Matthew was blocking severely on words and syllables,’ says Elisabeth,’ and I remember that on one of the videos Margaret sent me, he was squeezing his eyes together at the same time as he was trying to get a word out.’

Instructions were given to his mother in fortnightly telephone sessions, each lasting, on average, thirty minutes.  The treatment procedure and Matthew’s progress were carefully monitored by Elisabeth over a period of twenty-five weeks. The whole procedure took approximately double the time required for face-to-face treatment.  This was partly a result of the time required for speech samples to be gathered, then sent from England to Australia, and the difficulty involved in imparting the procedure over the telephone.

Because this treatment had never been attempted this way before, the Robinsons had to agree to certain conditions before the new procedure was trialled on their son. The team did not want to be responsible for a failed treatment on a child in Britain who would face a lifetime of stuttering. It was potentially very bad PR for the Lidcombe Program. So it was a condition that the family would come to Australia if the intervention by telephone and post failed. ‘We had a guarantee from family members to assist us with the fares if necessary,’ said Paul Robinson, ‘but it turned out to be quite unnecessary, as it all happened successfully down the telephone line. Matthew was completely cured, and he hasn’t relapsed since.’

‘The results were phenomenal—nothing short of a miracle,’ says Margaret Gibson. ‘Instead of ignoring the stutter, we were instructed during the telephone calls, to actually draw attention to his “bumpy words”. I didn’t realise until much later, that Elisabeth was carrying out detailed statistical analyses of  the audio samples and ratings that we provided. Within six months, his stutter was gone and has not come back.’

Favourable comments from the Gibsons did much to spur its current rapid proliferation throughout England. In an article entitled “Australian Therapists Help British Child” in 1995 edition of “Speaking Out”, the British Stammering Association magazine, his parents reported that ‘Therapy is tailored to Matthew personally. It’s simple, fun and builds confidence in speech, whilst ensuring that he remains confident about talking. Friends are astonished at the sustained improvement.’ The success of the treatment was further backed up by an article in the DailyTelegraph which hailed it as “a pioneering technique that tackles the problem head-on.”

Matthew is only one of thousands of children treated with the Lidcombe Program, since it was initially trialled on four preschoolers in 1990. Many others have been treated with this method here and in the United Kingdom, Canada, New Zealand, South Africa and the United States. However, a psychological perspective on stuttering in children that involves changing the family environment is still common in many countries.

‘Using behaviour modification was a dramatic reversal in the way stuttering had been treated over the years,’ says Professor Onslow. ‘And we received a lot of flak from educationists in Great Britain and the United States for daring to upset the status quo. In the end the clinical trials speak for themselves and we have made these available to all who request them.’

In fact, the first academics to think about the disorder in America in the 1950s were greatly influenced by psychoanalysis and sought to find out how stuttering reflected underlying unresolved neurotic conflicts about speech. One of these early researchers wrote of the “symbolic upward displacement of the anal sphincter.”

Later on, the treatment of stuttering in children became caught up in a conflict between psychological models, family dynamics, and behaviourism. The most widely accepted approaches involved not focusing on the child’s stutter, and ignoring it altogether in the hope that it would go away.  Behaviourism, and especially operant methods, were frowned upon for many years.

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One fine day in December 1982, Mark Onslow was reading an academic article while relaxing on the rocks by an ocean swimming pool near his home in Coogee. The paper he was reading was about a well-known experiment carried out by an American pioneer in stuttering theory: the 1970 Suzybelle Puppet experiment at the University of Minnesota. Two preschool aged children who stuttered were seated in a lab in front of a glass box containing a puppet. The talking puppet inside the illuminated box was operated from outside the room by an experimenter, who was the voice of the puppet. The preschool aged children conversed with the puppet inside the room for several minutes. Then, each time the child stuttered, the light was turned off for a few seconds making the puppet “disappear.” It was found that the children learnt to speak without stutters in order to access Suzybelle once again.

Onslow says: ‘After reading about this seminal experiment, I got up and dived into the salty water of Wylies Baths. I remember seeing starfish and seaweed and tiny sea creatures. And when I surfaced, I knew that I had hit upon a great idea: the parents of stuttering preschoolers could act as Suzybelle.’

And it was from this that the Lidcombe Program was eventually born, with the parent playing the role of Suzybelle.

‘In essence, the Lidcombe Program is a clinical model adapted from a scientific laboratory model.’

The two children in the Minnesota lab stopped stuttering and were able to maintain this after the experiment ended.  A tragic aspect of this study was that one of the children was killed in a car accident one year later. The other one, now an adult, is living somewhere in the United States.

And yet it was two decades after this laboratory experiment before a young Australian trailblazer and his team were able to develop a workable and successful model that has enabled thousands of children to be stutter free. The reason for the delay was that it was generally believed that drawing attention to a stutter in young children would worsen the problem or even cause it to be set in concrete.

Onslow goes on to tell how, during the fifties and sixties researchers had established that stuttering in adults could be brought under laboratory control with operant methods, including shock and loud noise, that were not usable in practice. It was unthinkable that anyone would try to make it work for children.

Much later on, a long-time academic friend visiting from Minnesota was shocked when he heard his younger Sydney University colleague focusing, be it ever so gently, on a child’s stuttered speech in the clinic at Lidcombe, a suburb in Western Sydney:

‘I winced every time I heard you correcting the child’s stutter. I felt like covering my ears with my hands, so much it seemed criminal to be focusing on it like that.’

The Lidcombe Program is now looked on as the best practice stuttering treatment for preschool age children in eight countries around the world, and formal training facilities have been set up in the United Kingdom, the United States and Canada.

The surviving American subject in the Suzybelle experiment is almost certainly stutter free, according to Professor Mark Onslow.

As for Matthew, he is now a successful engineer in his thirties, who, when asked about his early struggle to speak, replies articulately: ‘As far as I’m concerned, it never really happened.’ He would almost certainly not be where he is today, if it weren’t for the early intervention program.