Background: The Lidcombe Program is a stuttering treatment approach for children between the ages of 3 and 6 years. Most papers about the Lidcombe Program, however, are based on studies conducted in native English-speaking countries. The aim of this paper is to systematically review the delivery and implementation of the Lidcombe Program in non-native English-speaking countries. Summary: A resource search was conducted between October and November 2019. Scopus, PubMed, ASHA, Cochrane Library, ERIC, Google Scholar, and SpeechBITE databases and reference lists of relevant papers were searched for the identification process. Joanna Briggs Institute tools were used for the appraisal of the studies. The search yielded 8 studies conducted in non-native English-speaking countries. The Lidcombe Program is efficacious in non-native English-speaking countries when delivered to both preschool and young school age children who stutter. It is reported to be delivered with minor changes and challenges. The number of weekly clinic visits and the total time needed to reach zero or near-zero stuttering levels with the Lidcombe Program can be up to 3 times greater in non-native English-speaking countries than in native English-speaking countries, mostly due to the increased time needed to introduce the parental verbal contingencies. Key Messages: Speech and language therapists practicing in non-native English-speaking countries are encouraged to use the Lidcombe Program for both preschool and young school age children who stutter, although this can take more time than that reported in native English-speaking countries. Further investigation to explore the therapy process with children and parents in non-native English-speaking countries is needed.

Stuttering, which is characterized by repeated movements, fixed postures, and superfluous behaviors in the flow of speech [1], may complicate communication and can cause breakdowns when interacting with others. The worldwide prevalence of stuttering is reported to be about 1% regardless of race, ethnicity, culture, bilingualism, and socioeconomic status [2], with the highest incidence rate during the preschool years [2, 3]. The communication breakdowns due to stuttering can have a negative impact on the attitudes of preschool age children (age 3—6 years) who stutter when speaking with others [4] and can contribute to temperamental profiles such as inadaptability to changes and irregularity of daily routines [5]. Further, preschool age children who do not stutter can develop negative and/or uninformed thoughts and beliefs towards their stuttering peers even at that early age [6, 7].

If stuttering is not treated with early intervention or persists after the preschool years, its impact can be detrimental. School age children (age 7—12 years) who stutter have an increased risk of being teased or bullied [8, 9]. At later ages, stuttering may have negative effects on social-emotional functioning, mental health status, and quality of life, with an increased risk of developing social anxiety disorders [10, 11]. For the reasons above, stuttering should be addressed as early as possible in order to minimize the potential negative impact. Multiple reviews have concluded that the Lidcombe Program is the early stuttering therapy approach for preschool children who stutter for which most evidence is available [12‒14].

The Lidcombe Program is a stuttering treatment approach primarily developed for early stuttering [15, 16], but evidence also exists regarding its use in young school age children who stutter [17‒19]. The Lidcombe Program is comprised of operant principles that aim to increase fluent speech and decrease stuttered speech through the use of parental verbal contingencies, i.e., the fluent speech behaviors are reinforced whereas the child is given the opportunity to acknowledge the stuttered speech and repeat it fluently to increase fluent speech. Parents are required to attend 45- to 60-min weekly clinic visits with their children who stutter to learn and to implement parental verbal contingencies, first in practice and then in everyday conversations at home. Daily severity ratings are also given by the parents after a perceptual rating scale of 0 (no stuttering) to 9 (extremely stuttering) is taught to them. The children are not asked to change their speech patterns throughout the therapy process [15]. According to Harrison et al. [20], the Lidcombe Program is for that reason one of the best treatment options for pediatric stuttering. Weekly visits and daily practice and natural conversations continue until zero or near-zero stuttering levels are achieved (stage 1). Then, stage 2 starts in a less frequent attendance mode with the aim of maintaining the therapy gains. The parents are asked to withdraw the parental verbal contingencies gradually as the child becomes more fluent. They are also equipped with skills to cope with possible relapses after the therapy ends. Parents have found the Lidcombe Program enjoyable and reported increased quality time with their children and a reduction of stuttering [21, 22].

The efficacy of the Lidcombe Program in reducing stuttering in children who stutter has been reported in many experimental studies [e.g., 17, 23-27], case series [e.g., 28-30], and systematic reviews [e.g., 12‒14]. In addition, the efficacy of the Lidcombe Program’s voice-only telephone [31], webcam [32‒34], and preliminary internet-based application [35] has been reported to offer practitioners several options which, in particular, seem to be practical and can be cost-effective. Furthermore, group delivery of the Lidcombe Program is possible, not only implying an economic advantage and convenience but also offering some extra pedagogical benefits such as the initiation of new friendships that can lead to further development of interpersonal verbal skills [36].

It is possible for qualified Speech and Language Therapists worldwide to enroll in a 2- or 3-day training by the Lidcombe Program Trainers Consortium, headquartered in Australia [37], leading to an attendance certification. Of a total of 13 countries with availability of trainers, 5 are native English-speaking countries (Australia, UK, New Zealand, USA, and Canada) and 8 are non-English-speaking countries. Non-native English-speaking countries refer to countries where English is not one of the official languages dominantly used in government, educational institutions, media, and arts. Of a total of 23 trainers, 15 remain in 5 native English-speaking countries, whereas only 8 are present in 8 non-native English-speaking countries, which suggests a lack of trainers in non-native English-speaking countries worldwide. Similarly, the majority of the Lidcombe Program studies are conducted by researchers from native English-speaking countries (see for instance the reviews by Baxter et al. [12], Herder et al. [13], Nye et al. [14], Bothe et al. [38], and Johnson et al. [39]). Also, until now there have not been any qualitative studies investigating the experiences of the parents or children who have used the Lidcombe Program in non-native English-speaking countries [39]. The studies included in the quantitative systematic reviews mentioned above have a ratio of non-native English-speaking countries to native English-speaking countries of 6/37 [12‒14, 39]. As such, little is reported about the efficacy of the Lidcombe Program or about the experiences and thoughts of speech and language therapists and families who have received the Lidcombe Program in non-native English-speaking countries. Therefore, more investigation is required to understand how the Lidcombe Program is delivered in those countries. Information about the Lidcombe Program delivered in non-native English-speaking countries may assist speech and language therapists in non-native English-speaking countries with clinical decision-making in early stuttering cases. The impetus for the present study was some observations of the first author done while providing therapy to children who stutter in Ankara, Turkey. It occurred that parents sometimes had difficulty understanding and implementing parental verbal contingencies and complying with the Lidcombe Program requirements, such as daily practice sessions and filling in severity rating charts.

Review Questions/Objectives

The present work aimed to systematically review peer-reviewed and published studies related to the Lidcombe Program in non-native English-speaking countries to determine its efficacy.

The following review questions were addressed:

  • 1.

    What is the reported efficacy of the Lidcombe Program for treating preschool children who stutter between the ages of 2 years 6 months and 6 years 6 months in non-native English-speaking countries?

a. How many weeks does it take to reach stage 2 of the Lidcombe Program in non-native English-speaking countries?

b. How many (weekly) clinic visits are required to reach stage 2 of the Lidcombe Program in non-native English-speaking countries? (This is to reveal the session number required to reach stage 2.)

  • 1.

    Do speech and language therapists in non-native English-speaking countries need to make adjustments when delivering the Lidcombe Program? If so, what kind of adjustments?

  • 2.

    What are the reported challenges experienced by speech and language therapists, parents, and/or children in non-native English-speaking countries during treatment with the Lidcombe Program?

  • 3.

    What did the speech and language therapists and/or researchers from non-native English-speaking countries report about the applicability of the Lidcombe Program?

Inclusion Criteria

The inclusion criteria for the studies were: (1) recruiting preschool children between the ages of 2 years 6 months and 6 years 6 months, speech and language therapists, and parents who delivered or received the Lidcombe Program; (2) collected data until completion of the active treatment phase, i.e., stage 1, and achievement of the maintenance phase, i.e., stage 2, of the Lidcombe Program in a non-native English-speaking country; (3) following the manualized format of the Lidcombe Program treatment guide by Onslow et al. [15] (2019 or previous versions); (4) reporting speech fluency in the percentage of syllables stuttered or daily severity ratings; (5) peer-reviewed; and (6) published between 2000 and 2019.

Search Strategy

The following 3-step search strategy was utilized: (1) an initial limited search of PubMed and Scopus was undertaken to ensure that the search terms were able to detect relevant papers for the review, and an analysis of the title, abstract, and index terms was performed to identify relevant articles; (2) a search using the identified keywords and index terms was undertaken across the databases of ASHA, Cochrane Library, ERIC, Google Scholar, and SpeechBITE; and (3) the reference list of each identified article was checked for additional studies.

The databases were screened by the first and the last author independently using (“lidcombe program” AND [stutter* OR stammer*]) search syntax and “lidcombe” as a single keyword search. While this basic level search strategy revealed some papers from native English-speaking countries in addition to non-native English-speaking countries, this search string was used anyhow in order to not miss any papers from non-native English-speaking countries in any language.

In 3 papers, the oldest participant was older than 6 years and 6 months. Given the fact that a limited number of papers fulfilled the inclusion criteria, the authors agreed to include these papers in the review even though the child’s age fell just above the predefined age range.

Assessment of Methodological Quality

The selected papers were assessed by the first and last authors for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute tools [40]. In addition, the PRISMA checklist [41] was consulted to ensure that PRISMA requirements were met as well.

The search yielded 33 resources after the removal of 1 reduplicate. Sixteen sources (5 unpublished theses, 1 poster presentation, 9 non-peer-reviewed papers, and 1 book chapter) were excluded at the abstract level as they did not meet the inclusion criteria. Nine papers were excluded at full-text review due to irrelevant content, methodological weakness, and incompliance with the Lidcombe Program treatment guides or incomplete stage 1 treatment. The weaknesses of the studies excluded from the review have been detailed in the Discussion. Both authors agreed upon the inclusion of 8 papers after independently appraising the papers and reaching a consensus for each of the papers (Fig. 1).

Fig. 1.

PRISMA search and inclusion flow diagram.

Fig. 1.

PRISMA search and inclusion flow diagram.

Close modal

Data Extraction

Quantitative and qualitative data were extracted from papers included using the Joanna Briggs Institute extraction tools by the authors of the review [40]. The data extracted included specific details about the intervention, population, study methods, and outcomes of significance to the review questions and specific objectives agreed upon by the authors.

We found a total of 8 papers reporting the delivery of the Lidcombe Program in Europe, Oceania, and Asia (Tables 1, 2). All of the included studies were published in English, although that was not an inclusion criterion. As far as we could ascertain, no studies from the non-native English-speaking countries in the Americas or Africa emerged at any search stage throughout this study, except for an Egyptian study which did not meet the inclusion criteria. The study designs of the included papers comprised 1 qualitative, 1 experimental, and 6 case studies. The Lidcombe Program was delivered to the participants in official languages in Kuwait (Arabic), The Netherlands (Dutch), Sweden (Swedish), China (Mandarin Chinese), and Bulgaria (Bulgarian). It was delivered in languages other than formal languages in Iran (Baluchi) and Malaysia (Chinese and English).

Table 1.

Included quantitative Lidcombe Program studies conducted in non-native English-speaking countries

 Included quantitative Lidcombe Program studies conducted in non-native English-speaking countries
 Included quantitative Lidcombe Program studies conducted in non-native English-speaking countries
Table 2.

Included qualitative Lidcombe Program publication conducted in a non-native English-speaking country

 Included qualitative Lidcombe Program publication conducted in a non-native English-speaking country
 Included qualitative Lidcombe Program publication conducted in a non-native English-speaking country

All of the studies reported the percentage of syllables stuttered and severity ratings as outcome measures for the data collected from at least 2 different time points during treatment, even though the percentage of syllables stuttered is now an optional measure in the Lidcombe Program. Speech samples in and beyond clinic records of 10 min or 300 syllables were collected for all efficacy studies. In addition to the speech samples, Femrell et al. [24] used a questionnaire with parents and teachers to assess the effects of stuttering behaviors on the feelings and attitudes of those who stutter. Also, de Sonneville-Koedoot et al. [23] reported 9 outcome measures including communication attitudes, severity ratings by the children, and a child behavior checklist in addition to the percentage of syllables stuttered and severity ratings. The speech samples collected for this study comprised beyond clinic records with: (1) parents at home, (2) a non-family member at home, and (3) a non-family member away from home in order to increase the reliability of each time point measurement.

Efficacy of the Lidcombe Program in Children Who Stutter in Non-Native English-Speaking Countries

Seven efficacy studies replicated the role of the Lidcombe Program in reducing the stuttering severity of children who stutter in 7 different countries when delivered in 8 languages. Table 3 provides a summary of the efficacy studies.

Table 3.

Efficacy of the Lidcombe Program in non-native English-speaking countries

 Efficacy of the Lidcombe Program in non-native English-speaking countries
 Efficacy of the Lidcombe Program in non-native English-speaking countries

Number of Weekly Clinic Visits to Complete Stage 1 of the Lidcombe Program in Non-Native English-Speaking Countries

As shown in Table 3, three studies [23, 24, 30] reported that it required greater mean and median numbers of weekly clinic visits to reach stage 2 of the Lidcombe Program than the median number of 16 weeks that is mentioned in the treatment guide of the Lidcombe Program [15] based on several studies conducted in a total of 868 children. Jones et al. [42], Kingston et al. [43], and Koushik et al. [44] reported 11 sessions as the median number of weeks to reach stage 2 of the Lidcombe Program. Al-Khaledi et al. [28] delivered the sessions in a 60-min format, which is the upper borderline session duration according to the Lidcombe Program treatment guide [16]. They reported that parents required more time for parental verbal contingency training as they found it difficult to understand and implement.

Number of Weeks to Reach Stage 2 of the Lidcombe Program in Non-Native English-Speaking Countries

There appeared to be discrepancies between the number of weeks in total and the number of weekly clinical visits to reach stage 2 of the Lidcombe Program. The studies of de Sonneville-Koedoot et al. [23] and Simonska [45] did not report data regarding the total duration and clinical visit numbers (Table 3). The total duration for reaching stage 2 was extended due to parents missing weekly sessions. Speech and language therapists had difficulty getting parents to attend weekly treatment sessions due to issues including holidays [29], driving restrictions for women, and reluctant attitudes of fathers towards following up their children’s therapy programs [28].

Facilitating the Delivery of the Lidcombe Program

Adaptations pertaining to the content and the delivery of the Lidcombe Program in non-native English-speaking countries were sometimes used to facilitate the therapy process, comparable to those reported in native English-speaking countries. Hewat et al. [29] used stickers and game pieces that made the praise more concrete, together with gestures and facial expressions. Bakhtiar and Packman [17] reported the use of 2 languages while involving other family members in the delivery of the Lidcombe Program. For convenience purposes, Vong et al. [30] conducted a mixed delivery mode including both face-to-face and videoconference. Table 4 provides more details.

Table 4.

Adjustments, challenges, and thoughts on the applicability of the Lidcombe Program in non-native English-speaking countries

 Adjustments, challenges, and thoughts on the applicability of the Lidcombe Program in non-native English-speaking countries
 Adjustments, challenges, and thoughts on the applicability of the Lidcombe Program in non-native English-speaking countries

Challenges Reported during the Delivery of the Lidcombe Program in Non-Native English-Speaking Countries

Four studies reported challenges that parents faced during the delivery of the Lidcombe Program [24, 28, 29, 45]. The themes for these challenges were less parental involvement and attendance [28, 29], requiring more time to understand and implement parental verbal contingencies [28, 29], finding parental verbal contingencies unnatural [28], using corrections more than praise [28, 29], finding the Lidcombe Program demanding and time-consuming [24, 28, 29], being unaccustomed to operant conditioning and praising [24, 29], and avoiding the provision of parental verbal contingencies for stuttered speech [45]. Table 4 provides more details.

Thoughts on the Applicability of the Lidcombe Program in Non-Native English-Speaking Countries

Findings from Quantitative Studies

The delivery of the Lidcombe Program was found to be efficacious in 7 different non-native English-speaking countries in both preschool and school age children who stutter, as seen in Table 4. Bakhtiar and Packman [17] and Vong et al. [30] reported that the Lidcombe Program was responsive to parenting styles and cultural assets. The Lidcombe Program experience was rated as positive by the speech and language therapists [24, 45] and the parents recommended the Lidcombe Program to others, although they reported the program as demanding [24]. Furthermore, the Lidcombe Program was proposed as an evidence-based approach in The Netherlands according to a large-scale randomized controlled study (RCT) [23].

Findings from the Qualitative Study

The only qualitative paper included in this review collected data from speech and language therapists who participated in the RESTART-DCM study of de Sonneville-Koedoot et al. [23]. These were collected during focus group interviews [46]. Findings underlined that the speech and language therapists shifted their preference for the therapy approach from “what is the best” to “what is the best fit” for the children and their parents. Please see Table 5 for details.

Table 5.

Thoughts of the speech and language therapists on the applicability of the Lidcombe Program in The Netherlands from a qualitative aspect

 Thoughts of the speech and language therapists on the applicability of the Lidcombe Program in The Netherlands from a qualitative aspect
 Thoughts of the speech and language therapists on the applicability of the Lidcombe Program in The Netherlands from a qualitative aspect

Efficacy of the Lidcombe Program with Children Who Stutter in Non-Native English-Speaking Countries

Eight papers met the inclusion criteria of this systematic review to address the use of the Lidcombe Program in non-native English-speaking countries. According to the review results, the Lidcombe Program in non-native English-speaking countries has been found to be efficacious in different cultures and languages, with varying treatment durations for reaching stage 2, minor modifications of the Lidcombe Program delivery, and minor challenges. The seven studies replicated the efficacy of the Lidcombe Program on reducing the stuttering severity of children who stutter, including bilingual children, in various countries and languages even though some issues have been reported. These included longer periods to reach stage 2 of the Lidcombe Program and difficulty complying with the requirements of the therapy program. In general, the parents and children in non-native English-speaking countries have developed positive attitudes towards the Lidcombe Program therapy process consistent with gains in speech fluency. However, it should be noted that the level of evidence of the majority of the papers in this review was level 4 of the Joanna Briggs Institute evidence hierarchy as they mostly consisted of case studies (Table 1) [47]. There was only 1 study at the first level of evidence hierarchy in this review [23].

Duration Required to Reach Stage-2 of the Lidcombe Program in Non-Native English-Speaking Countries and Parental Verbal Contingencies

According to the Lidcombe Program studies with a total of 868 preschool children who stuttered, the median number of clinic visits required to reach stage 2 of the Lidcombe Program is 16, with a range of 11–23 in individual studies [15]. A similar duration was reported in 4 studies [17, 28, 29, 45]. Some of the reasons for a longer treatment duration to reach stage 2 of the Lidcombe Program in non-native English-speaking countries compared to native English-speaking countries can be explained by less parental participation in the therapy process and previous educational and therapeutic experiences that contrast with the Lidcombe Program, such as drill activities [24, 28, 29]. Also, de-Sonneville et al. [23] reported that reaching stage 2 of the Lidcombe Program took longer in The Netherlands than the time frames reported in native English-speaking countries. Although the Netherlands is a Western European country, the experienced challenges were similar to those in other Middle Eastern and Asian countries. In general, it can take longer to reach stage 2, and require more clinical visits and be more effortful, in non-native English-speaking countries compared to native English-speaking countries, probably for the reasons stated above. It remains unknown whether missing weekly clinical sessions can systematically increase the number of sessions required to reach stage 2 of the Lidcombe Program in addition to the total duration.

The fact that the frequency and character of praise may vary depending on culture can cause longer learning and applying principles of the Lidcombe Program in some countries. The operant principles, the main facilitators of the Lidcombe Program, were not found to be the usual way of raising children in Sweden [24] and China [29]. Parents in Kuwait and China do not tend to praise their children, especially not verbally [28, 29]. Parents in Kuwait, Sweden, and Malaysia find verbal praise to be unnatural [24, 28, 48]. Some parents who received the Lidcombe Program tended to correct their children’s behaviors rather than praise them. This was reported by parents in Kuwait and China [28, 29]. This, however, was also noted in Lidcombe Program implementation in native English-speaking countries [49]. An explanation for this could be that the participants of some studies conducted in Australia, a multicultural country, might have been selected from a different culture. However, in Bulgaria, some parents avoided giving parental verbal contingencies for stuttering as they assumed that this could increase stuttering awareness and consequently stuttering severity but praised as required [45]. Although some cultures are not familiar with parental verbal contingencies used with the Lidcombe Program, speech and language therapists can identify such issues related to the successful implementation of the Lidcombe Program with parents and obtain outcomes similar to those reported in native English-speaking countries probably in a longer period of time.

According to the studies conducted in native English-speaking countries, the most frequently used parental verbal contingency is “praise,” and parental verbal contingencies given for unambiguous stuttering tend to increase the length of stage 1 [50]. Parental requests for self-correction, a parental verbal contingency given for unambiguous stuttering during Lidcombe Program implementation, were associated with longer treatment times [51]. Parental verbal contingencies for stuttered speech can lead to the development of undesired reactions in children, such as being annoyed about the parental verbal contingencies or thinking that stuttering is a mistake [21]. As such, implementation of the Lidcombe Program can be complicated when there is no satisfactory progress with the children’s stuttering levels [21, 22]. In non-native English-speaking countries, however, according to the results of a detailed feasibility study for the Lidcombe Program implementation in Malaysia, parents provide significantly more acknowledgments than praise [48]. Parents did not praise their children when they behaved well but did praise their children more frequently after misbehavior, to promote the behavior change, which is different from the data collected in native English-speaking countries and not consistent with the operant conditioning principles adopted by the Lidcombe Program. In addition, the diversity of praise expressions was limited. Parents also used praise words in English, although there existed reciprocal expressions in their own languages. Possibly, parents found the use of praise in English more natural as they believe praise is a Western habit. Instructing parental verbal contingencies, especially praise, was reported to take more time, which resulted in longer times to reach stage 2 of the Lidcombe Program in Malaysia [30]. Following the feasibility study [48], Vong et al. [30] reported that a reduction in stuttering was observed after delivery of the Lidcombe Program to preschool children who stutter, even in bilingual children, with longer periods of time compared to studies in native English-speaking countries. The parents, however, were not resistant to learning to provide the parental verbal contingencies including praise. Positive nonverbal responses such as tonal and facial expressions often sufficed for obtaining positive results with Malaysian preschool children who stutter.

The findings from this review confirm that it can take longer to reach stage 2 of the Lidcombe Program in non-native English-speaking countries for various reasons, but even this finding should be interpreted cautiously before generalizing the results as it was found in single case studies. In addition to this, Simonska [45] reported that there was no positive correlation between the stuttering severity and the number of sessions according to her data for the study in Bulgaria, contrary to the fact that it took longer to reach stage 2 if the percentage of syllables stuttered was more than 5, as reported in Sweden [24]. This finding was based on data from a low number of participants; however, the other papers also had low numbers of participants and such findings were not reported in any of them.

Age Categorizations for the Studies Conducted in Non-Native English-Speaking Countries

Some authors did not follow common age categorizations when recruiting participants for their studies. That is, in some studies children older than 6 years were recruited. Therefore, the results and generalizations drawn from those studies can be criticized. For example, de Sonneville-Koedoot et al. [23] set the inclusion age between 3 and 6.3 years. Age is mostly limited to 6 years when a study is conducted within the preschool population [26, 32, 52]. It is generally above 6 years when school age children who stutter are studied in papers from native English-speaking countries [44, 53]. Some studies, including those that were excluded from the review, disregarded this upper boundary of preschool children who stutter. For example, Rifaie et al. [54] determined the age range between 4 and 7.5 years, Simonska [45] between 3.2 and 6.9 years, and Abou El-Ella et al. [55] between 3 and 8 years. To understand clinical implications and draw strong conclusions, it is important to study a single population with standardized age ranges, especially when designing experimental studies. Although the age of starting school may vary among different countries, a common terminology for preschool and school age children who stutter should be identified globally.

Qualitative Studies in Native and Non-Native English-Speaking Countries

The qualitative study included in the review investigated the experiences and attitudes of speech and language therapists in The Netherlands who delivered treatment in the RESTART-DCM study [46]. The study revealed that, besides the parents and children who received the Lidcombe Program, the therapists played a significant role in the therapy process. As the speech and language therapists went through the RESTART-DCM study, their beliefs and attitudes toward the different treatment approaches were changed. In other words, the clinical decision-making skills of the speech and language therapists after the study changed from “only external evidence referenced” to “a combination of external and internal evidence referenced,” as suggested by Dollaghan [56]. In other words, speech and language therapists considered: (1) their own experiences and insights, (2) the beliefs and features of clients, and (3) evidence from research studies in the clinical decision-making process, rather than focusing only on external evidence.

The findings from this qualitative study replicate the importance of further training and qualitative exploration. The literature lacks qualitative data collected directly from children and parents who received the Lidcombe Program in non-native English-speaking countries.

A comprehensive qualitative study conducted in Australia, a native English-speaking country, revealed some similarities with non-native English-speaking countries [21]. According to Goodhue et al. [21], Lidcombe Program implementation was reported as a time-demanding treatment by parents in Australia; this was also observed with parents in Sweden [24] and China [29]. However, the challenges faced by the parents in Australia were mostly based on remembering and finding time for the practice sessions at home, whereas parents in China [29], Sweden [24], and Kuwait [28] were reported to require more time to get used to the content of the Lidcombe Program, such as using praise, taking the role of a therapist, and giving fewer corrections to children on their stuttered speech. Although such challenges were reported both in native and non-native English-speaking countries, the parents reported that the children enjoyed the therapy sessions.

Delivering the Lidcombe Program in a Limited Number of Sessions

Five studies were excluded from the review because the number of weekly clinical visits on which authors reported was limited to 12 [25, 54, 55], 16 [27], or 36 [57] for all participants in their research protocols. The participants of these studies did not reach stage 2 of the Lidcombe Program based on the data provided [15]. Because they used this set-up in their study, they were excluded from this review as they could not answer the first research questions. Some studies (e.g., Harris et al. [58] and Lattermann et al. [27]) at earlier stages of Lidcombe Program research limited the number of sessions for reasons such as testing the safety and proving the efficacy of the program. However, today, there is no need to further prove the safety or the efficacy of the Lidcombe Program in such limited sessions; instead, there is a clear need for evidence of zero or near-zero stuttering levels through the Lidcombe Program without a timeframe limitation.

Study Designs of the Studies Conducted in Non-Native English-Speaking Countries

The study designs included in this review were merely case studies, except for 1 experimental study. The study by de Sonneville-Koedoot et al. [23] was a large-scale study at the first level of evidence hierarchy and the remaining 6 studies comprised case studies at the fourth level of evidence hierarchy according to Joanna Briggs Institute [47]. Case studies do not provide the highest level of evidence, but they become meaningful when all of them report similar data and issues. Although there is only 1 study with the highest level of evidence in this review, it should also be noted that the other studies supported the findings of this experimental study. The replication of the discoveries makes the findings of this review meaningful and strong. Nevertheless, there is a clear need for building a higher level of evidence to promote the use of the Lidcombe Program among speech and language therapists in non-native English-speaking countries, such as in studies conducted in The Netherlands [23, 25].

Stuttering is a multidimensional speech disorder with social and emotional components that should be investigated thoroughly [5, 6, 59, 60]. This investigation, without a doubt, should consist of lived experiences through qualitative methods especially in the case of cross-cultural adaptation of an intervention. This can be achieved by designing mixed-method studies that include both quantitative and qualitative methods. However, this review yielded 3 quantitative studies providing also qualitative data [24, 28, 29]. These studies included qualitative aspects; however, a qualitative methodology was absent, which may impact the credibility of the qualitative findings. Future studies with the Lidcombe Program, especially those in non-native English-speaking countries, should contain both quantitative and qualitative methods with rigorous data analyses for both methodologies to get extensive and reliable insights. Currently, there are no qualitative studies investigating the implementation process by parents and children according to the results of this review. However, the fact that a qualitative investigation in Australia revealed a number of challenges faced by speech and language therapists and parents [49] suggests possible challenges implementing the Lidcombe Program in non-native English-speaking countries, underscoring the need for more qualitative explorations outside of native English-speaking countries.

Bilingualism and the Lidcombe Program in Non-Native English-Speaking Countries

The Lidcombe Program was delivered successfully in a combination of 2 or more languages in a few cases [17, 30, 61]. To respond to many of the needs of multilingual countries in terms of early stuttering treatment, the search for this systematic review also yielded evidence for bilingual preschool children who stutter when the Lidcombe Program is delivered. One of the main advantages of the Lidcombe Program over other therapy approaches is that it is the parents who deliver the therapy. As such, a speech and language therapist can deliver the treatment to a child in a language other than the language he or she speaks him- or herself if this is the only option in some cases. The speech and language therapist may choose to instruct a third person such as a parent or guardian to deliver the Lidcombe Program in the native language of the child. This approach seems to result in similar outcomes in the English-Dutch language dyad [61]. Bakhtiar and Packman [17] reported a significant reduction in stuttering over a 10-month period in a bilingual school age child who stuttered in Persian and Baluchi in Iran. In the procedure of this single case study, the father delivered the structured therapy in Persian while unstructured therapy components were delivered in Baluchi by other family members. Daily severity ratings were obtained from parents in Baluchi and the percentage of syllables stuttered was obtained in the clinic in Persian by the speech and language therapist. Vong et al. [30] successfully reduced the stuttering severity of 2 bilingual preschool children who stutter in Mandarin Chinese and English by delivering the Lidcombe Program intervention in only 1 language, which resulted in similar gains in other spoken languages as well.

Although Bakhtiar and Packman [17] and Vong et al. [30] delivered the Lidcombe Program in linguistically diverse contexts, the clinic visits required to reach stage 2 of the Lidcombe Program differed significantly (Table 3). In Malaysia, where there were more languages that the participants used than those in Iran, it took more than 3 times the number of clinical visits in Iran. However, it should be noted that the data was derived from a limited number of subjects, and more data is required to understand whether cultural and linguistic diversity has any potential to increase the time needed to reach stage 2 of the Lidcombe Program.

Hybrid Delivery Modes of the Lidcombe Program

The facts that speech and language therapy is an emerging profession in some non-native English-speaking countries [30, 62] and that the access to a speech and language therapist can be difficult, convenient delivery modes of the Lidcombe Program such as telephone, videoconference, or a mixture of these options together with in-clinic options can be planned for either preschool or school age children who stutter, as it was used successfully by Vong et al. [30]. Such a hybrid mode will not only increase access to remote populations but also help parents maintain attendance at weekly sessions even when compelling reasons such as the COVID-19 pandemic exist both in native English-speaking countries and in non-native English-speaking countries. Future research should focus on the efficacy of such a delivery mode.

Limitations and Further Directions

It should be noted that the majority of the papers included in this review comprised case studies, which means that the findings have to be cautiously interpreted for clinical translations.

The research studies of the Lidcombe Program conducted in non-native English-speaking countries confirm that parental verbal contingency training for parents may take longer and require more effort compared to those in native English-speaking countries when delivery of the Lidcombe Program can result in longer periods to reach stage 2. However, the power of each of the 5 verbal contingencies used in the Lidcombe Program is not really known. Donaghy et al. [63] investigated the components of the Lidcombe Program and reported that further investigation was required to understand this treatment component. The results of such studies may reduce the number of parental verbal contingencies and consequently the time required to teach them to parents. Also, the compliance of parents with the Lidcombe Program and regular attendance to sessions can be areas that require more focus. In short, future research could investigate: (1) the efficacy of each parental verbal contingency to determine whether fewer parental verbal contingencies can obtain similar results and (2) the efficacy of a mixed delivery mode of the Lidcombe Program comprised of both in-clinic and videoconference options in non-native English-speaking countries as this may be a solution to reduce missing weekly sessions.

The Lidcombe Program is an efficacious early stuttering therapy program developed in English and in Australia which is also delivered in non-native English-speaking countries with minor adaptations and challenges. The Lidcombe Program can meet the needs of bilingual children and families and seems to be deliverable in a multilingual context even when the service deliverer and the child do not speak the same language. However, further quantitative studies with larger numbers of participants who have reached stage 2 of the Lidcombe Program and qualitative studies investigating the experiences of speech and language therapists, parents, and children who have been a part of the Lidcombe Program are needed. Although children are the most important participants of Lidcombe Program-related research, qualitative data regarding those children are missing. However, both quantitative and qualitative approaches should be used in a methodological manner and analyzed accordingly.

Reaching stage 2 of the Lidcombe Program in non-native English-speaking countries can take longer than in native English-speaking countries. This is probably due to the need to teach parental verbal contingencies to parents as they are often not accustomed to providing certain types of parental verbal contingencies used in the Lidcombe Program. Speech and language therapists in non-native English-speaking countries should be aware of this prior to commencement of the Lidcombe Program and an attempt to inform parents of the demands and requirements of the Lidcombe Program to prevent leave-outs or difficulties throughout the therapy process. Speech and language therapists could regularly ask for videos of home treatments so that they can make sure that the parents are implementing the parental verbal contingencies well and correctly. Lastly, considering that parents in non-native English-speaking countries can require more assistance with the implementation of the Lidcombe Program, speech and language therapists in such countries should be equipped with relevant information, and training provided by the Lidcombe Program Trainers Consortium can be adapted to the needs and concerns specified in this review.

An ethics statement is not applicable because this study is based exclusively on published literature. An ethics statement is not required for this study type as no human or animal subjects or materials were used.

The first and second authors have no conflict of interests to declare. The last author is a member of the Lidcombe Program Trainers Consortium.

The authors did not receive funding for this study.

All of the authors contributed to the study design, interpretation of data for this work, critical revision for important intellectual content, and final approval of the version to be published. All of the authors agree to be accountable for all aspects of this work.

All of the data generated or analyzed during this study are included in this article and its online supplementary material (see www.karger.com/doi/10.1159/000517650 for all online suppl. material). Further inquiries can be directed to the corresponding author.

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