Friday, March 13, 2015

Lidcombe the only effective treatment in Australia?

US cultural imperialism, this time for good reasons, has struck Australia. The Australian government and speech and language association has plans to make Lidcombe the unique treatment option available for clinicians to treat stuttering kids, because it is the most studied and has been proven effective. As we all know, this campaign is very likely led by Prof Onslow and his people. He is very much Mr Stuttering in Australia, and sucks up most of the research funding and probably sits on the research council board to decide on other people's funding. He was also so kind to send me a nice letter from his university's lawyer a few years ago, and was very eager to have a few nice chats with the director of a Dutch researcher who wanted to compare Lidcombe with another treatment option - an episode that she has still not spoken publicly about. I wonder what would happen if she were to write an open-ed in a main Australian newspaper about this episode?

So as you see, we again need the Americans to police the world! Soft power of course. Australia deserves an opinion that opposes the opinion of the lords of the lands down under. A petition by Craig Coleman does exactly this:
Recently, Speech Pathology Australia (the national speech-language pathology association of Australia) submitted a proposal to the Australian Government Department of Treasury that would require Medicare rebates be made available for children who stutter, but only if they are treated using the Lidcombe Program. 
The ramifications for this action are significant. As expected, many speech-language pathologists from the U.S. and abroad do not support this action for several reasons. First, this action gravely limits the scope of treatment for stuttering. Many interventions for preschool stuttering have shown to be effective (Millard, Nicholas, & Cook, 2008; Yaruss, Coleman, & Hammer, 2006; Franken, Kielstra-Van der Schalk, & Boelens, 2005).
So what is my opinion?

  1. I disagree with both positions (Come on, you certainly did not expect me not to have my own opinion!) but support the petition as a matter of principle.
  2. Lidcombe has not shown to be effective in a serious trial setting. No long-term control group. No good long term data. Little control of relapse. Much anecdotal evidence from clinicians that says that it did not work for some of their clients.
  3. Lidcombe has not shown to be more effective than Demands & Capacity treatment as shown in Franken's trial but still not published, much to my serious frustration and not due to any evil forces from Australia!
  4. The Franken trial has not shown that any treatment is highly effective as they looked at the relative performance of both treatments. No control group was present.
  5. The Millard and Yaruss studies are weak on the methodological side.
  6. The statement "Many interventions for preschool stuttering have shown to be effective" is plainly wrong because no control group and long-term data existed to cater for natural recovery.
  7. It goes against my belief system! I believe that at the age when the kids starts stuttering the brain is already so f*****d up neurobiologically in those kids that will not recover that you can only mostly improve psychosocial adaptation. The other kids who stutter and recover have a normal neurobiology but delays in some brain regions needed to generate fluent speech. Once the delayed regions mature, they are fine with or without treatment.
  8. Psychotherapy research has shown that any treatment approach can work and that the success criteria No 1 is the patient-client relationship and the quality of the clinician. No matter what she (look I am gender-aware!) does: if she is good, it will help.
  9. And here we come to what really helps. Anyone who gets emails from desperate (and some hysterical) mothers (yes, no fathers) about their stuttering child knows that those who need treatment most are the parents (and especially the mothers) to help their children adapt psychosocially to a handicap, should they not recover. It is also them who need to practise with the kids and help them develop well as a person.
As a conclusion, I would say that this is a brilliant example of how good intentions can lead to a bad impact. Yes, we need science and a scientific approach. But stuttering is so complex (due to its neurobiological and biopsychosocial nature) that a commonly used scientific approaches to intervention such as random control trials are like minefields of statistics, biases, and more. In my experience, no professional stuttering expert has the statistical, mathematical, and scientific mind in combination with good funding and a control of the experimental subjects necessary to conduct these trials rigorously. So necessarily, the results look good but they are hollow. And the results to the clinicians, politicians, and public good enough to make a political choice. I think they do not.

So I say: Let us educate clinicians to become expert on stuttering and let them decide what they want to use. They need to feel comfortable to be focused and motivated to treat children.


Jill Saunders said...

Dr. Weidig,
I do not support the petition because they shouldn't be the ones deciding how people get treatment. You also said you do not agree with it, so what do you mean by saying that you support them as a matter of principle?

Tom Weidig said...

>> I do not support the petition because they shouldn't be the ones deciding how people get treatment.

But how else should decide? Should you decide that only one treatment is valid?

>> You also said you do not agree with it, so what do you mean by saying that you support them as a matter of principle?

I said I do not agree that "other studies have shown that other treatment approaches are effective." I hold the belief that no treatment has been shown clearly effective and clearly better than any other treatment. Therefore, I am against choosing only Lidcombe as a treatment option.

Brooke Leiman said...

Jill- I believe you misread what Tom wrote. He supports Craig's petition against SPA's proposal. He went on to say he didn't agree with everything Craig stated but that he supports him on a matter of principle. I think you were interpreting it as if he was supporting the SPA proposal, which I do not believe is the case.

Tom Weidig said...

@Brooke: Yes, that's correct. I support the petition because I believe that no one treatment approach has shown to be significantly better than another one. However, I also did say that the petition assumes that early childhood intervention treatment is very effective, which I believe has not been clearly proven.

Anonymous said...

Great post. Love your informative and honest posts - please post more

Anonymous said...

Mr. Weidig -

I must disagree with you. Dr. Scott Yaruss is a giant in the area of stuttering; his research and efficacy are indisputable.

You should speak with him before you discredit him.