Marie-Christine Franken, University Medical Center, Rotterdam, The Netherlands
Some 40 years ago, the notion arose that the success of stuttering therapy in its advanced stages (be it important for the individuals concerned) was limited on public health scale. One began to explore early intervention methods to eliminate stuttering at the time it begins. That desire was not without controversy. Apart from - mainly medical - thoughts that early therapy was not required (‘it will naturally disappear’), the notion that directing attention to stuttering was the cause of the problem dominated the professional thinking, esp. in the north-western part of the world.
For that reason, in Europe, the first early intervention approaches of stuttering were indirect: treatment was focused on decreasing communicative stressors and, to a lesser extent, on strengthening the child’s skills for speaking fluently. The approach by Starkweather and his colleagues, known as the Demands and Capacities Model based treatment, became the standard treatment in the Netherlands (Starkweather, Ridener Gottwald, & Halfond, 1990). Parents of children who stutter were instructed to decrease communicative demands, such as slowing down their articulation rate, inserting more pauses, and asking few questions. The child’s capacities for speaking fluently were also trained, such as learning the rules for turn taking. Parents practiced these changes 15 minutes a day while playing with their child and giving it their full attention. Doing so, the child was allowed time to mature and overgrow the speech impediment at their own (but extra given) pace. The effectiveness of this version of DCM-treatment has not been investigated in a randomized trial, but very positive outcomes for 60 children who were treated with this approach were reported (Starkweather & Gottwald, 1990). In Australia on the other hand, Onslow and his colleagues started to develop a direct, response contingent treatment for preschoolers to eliminate stuttering (Onslow, Costa, & Rue, 1990). Compared to the north-western indirect treatment approach, parents were taught to acknowledge and praise fluent speech and to acknowledge and request self-corrects after stuttered speech. The contrast with the conspiracy of silence way of dealing with stuttering in young children in the preceding half of the century couldn’t be bigger.
Adepts of these two (indirect and direct) approaches formed themselves in ‘schools’. The effectiveness of the Lidcombe Program (https://www.uts.edu.au/sites/default/files/2020-07/Lidcombe%20Program%20Treatment%20Guide%202020%201.0_1.pdf) has been studied frequently, however, in relatively small groups and with few participating clinicians. Jones et al. (2005) included the highest number of children (29 experimental children and 25 control children), who were treated by two clinicians. It became of paramount interest to comparatively study the therapeutic strengths and possible weakness of the indirect and direct treatment approach. This is what Franken et al (Franken, Kielstra-Van der Schalk, & Boelens, 2005) first did in a preliminary study over a three month treatment period (11-12 sessions). The decrease in the frequency of stuttering was comparable for the two approaches. Having shown that a comparison of the two approaches was feasible, a large scale comparison was aimed at including much larger groups than published so far and many participating clinicians outside the university clinics. That indeed were the two goals we set out to study in 2007, being helped by the fine-meshed medical society in the Netherlands.
After having reached a consensus about the DCM-treatment protocol (https://restartdcm.nl/wp-content/uploads/2021/07/RestartDCM-Method-2021_online.pdf) with more than 20 participating clinicians, our RESTART-study encompassed 198 preschool children who had stuttered at least 6 months before treatment onset. About one quarter of the children had already stuttered 13-18 months and about one third 19 months or longer. The eligible children were randomized by a computer (minisation) program in two groups of 99. Results have been amply described (de Sonneville-Koedoot, Adams, Stolk, & Franken, 2015; de Sonneville-Koedoot, Bouwmans, Franken, & Stolk, 2015; de Sonneville-Koedoot, Stolk, Rietveld, & Franken, 2015) At the endpoint of the study, 18 month post randomization, roughly 73% of the children were found to show no or very little stuttering. The outcomes in the Lidcombe Program arm did not significantly differ from those in the Restart-DCM based treatment arm. Evidently, because the Lidcombe Program had been shown to be an effective therapy (Jones et al 2005), it was ethically not allowed to include a no treatment control group. However, the proportion of children with no or very little stuttering post onset treatment was compared with the natural recovery of historical controls (Yairi and Ambrose, 1999). In this group of children from the general population (not the clinical population) included shortly after the onset of stuttering, 74% was recovered from stuttering 4 years after onset. 9 percent of children was recovered from stuttering in the first year after onset, and most children recovered from stuttering 2-3 years after onset. At first glance, the results of the two therapy groups in the RESTART-study might not differ from the historical controls. However, the participants of two therapy groups all consisted of children stuttering in an alarming way (which doubtfully may apply for the general population) and the recovery has come much faster. Last but not least, as described above, the children in the treatment groups had a significant longer time since stuttering onset than the historical controls, contrary to our recent Dutch clinical guidelines, where start of therapy is advised much earlier. A longer time since onset is well known to be associated with a lower natural recovery rate from stuttering. Therefore, comparison with a control group may not be possible anyhow.
With respect to the notion that direct early intervention might be harmful, it is not without interest that the fluency improvement in the Lidcombe group appeared to be a little faster; i.e. three months after onset of treatment, the frequency of stuttering of children in the Lidcombe group had decreased slightly more than in children in the Restart-DCM group. We don’t know whether this will hold in other, similarly comparable powered studies, but so far the atavistic fear of doing harm by early intervention, doesn’t seem to be the case.
In follow up, we currently are studying the long-term outcomes of the RESTART-study as well as possible genetic differences within various subgroups.
de Sonneville-Koedoot, C., Adams, S. A., Stolk, E. A., & Franken, M. C. (2015). Perspectives of Clinicians Involved in the RESTART-Study: Outcomes of a Focus Group. Am J Speech Lang Pathol, 24(4), 708-716. 10.1044/2015_AJSLP-14-0215
de Sonneville-Koedoot, C., Bouwmans, C., Franken, M. C., & Stolk, E. (2015). Economic evaluation of stuttering treatment in preschool children: The RESTART-study. J Commun Disord, 58, 106-118. 10.1016/j.jcomdis.2015.10.006
de Sonneville-Koedoot, C., Stolk, E., Rietveld, T., & Franken, M. C. (2015). Direct versus Indirect Treatment for Preschool Children who Stutter: The RESTART Randomized Trial. PLoS One, 10(7), 10.1371/journal.pone.0133758
Franken, M. C., Kielstra-Van der Schalk, C. J., & Boelens, H. (2005). Experimental treatment of early stuttering: a preliminary study. J Fluency Disord, 30(3), 189-199. 10.1016/j.jfludis.2005.05.002
Jones, M., Onslow, M., Packman, A., Williams, S., Ormond, T., Schwarz, I., & Gebski, V. (2005). Randomised controlled trial of the Lidcombe programme of early stuttering intervention. BMJ, 331(7518), 659. 10.1136/bmj.38520.451840.E0
Onslow, M., Costa, L., & Rue, S. (1990). Direct early intervention with stuttering: some preliminary data. J Speech Hear Disord, 55(3), 405-416. 10.1044/jshd.5503.405
Starkweather, C. W., & Gottwald, S. R. (1990). The demands and capacities model II: Clinical applications. J. Fluency Disord., 15(3), 143-157. https://doi.org/10.1016/0094-730X(90)90015-K
Starkweather, C. W., Ridener Gottwald, S., & Halfond, M. M. (1990). Stuttering Prevention: A Clinical Method Prentice Hall