Lexipontix Program: Facilitating Change toward “Best Hopes” of the School-Age Child Who Stutters and the Family

Abstract

Lexipontix is a structured therapy program for school-age children who stutter. It is based on theoretical principles and clinical practices of cognitive behavioral therapy, parent–child interaction therapy, solution-focused brief therapy, fluency shaping, and stuttering modification. A case example of a school-age child who stutters and his family who participated in the Lexipontix program is illustrated to highlight the theoretical principles, structure, content, and clinical tools of the assessment and therapy process of the program. The Lexipontix program addresses the stuttering experience of the child and family in a holistic way. The child and family are assisted in facilitating changes in all components of the International Classification of Functioning, Disability, and Health model (i.e., body function, personal factors, activity and participation, environmental factors), which help them move toward their “best hopes” (i.e., personally meaningful change) from therapy. The role of the clinician in facilitating change is also considered. Therapy outcomes for the specific case example are presented and discussed in relation to data from a retrospective chart review. The mechanisms underlying the effectiveness of the program are explored and discussed.

Keywords

Lexipontix program - school-age child - best hopes - stuttering - ICF

Learning Outcomes: As a result of this activity, the reader will be able to (1) apply the International Classification System of Functioning, Disability, and Health (ICF) model in the assessment and treatment planning for school-age children who stutter; (2) describe the key elements of the Lexipontix program and the role of the therapeutic alliance between the therapist, the child, and their parents in therapy; (3) apply principles of the Lexipontix program to the assessment and treatment of school-age children who stutter; (4) discuss the benefits of a holistic approach to stuttering therapy.

Lexipontix is a structured therapy program for school-age children who stutter (CWS).[1] [2] [3] It is based on theoretical principles and clinical practices of cognitive behavioral therapy (CBT),[4] [5] [6] parent–child interaction therapy(PCI),[7] [8] solution-focused brief therapy (SFBT),[9] [10] [11] and fluency shaping[12] and stuttering modification strategies.[13] [14] The therapy program aims to address the stuttering experience of the child who stutters in a holistic way, to help the child initiate positive changes in activity and participation in everyday life, and to improve the child's and family's quality of life. Parents and child are engaged in therapy as equal partners.[15] [16] Therapy is built on a child-friendly theme and is fun and intuitive. Most importantly, Lexipontix emphasizes exploring and understanding the child's stuttering experience, finding novel ways of managing it, and ultimately producing meaningful changes.[17] [18] [19]

The purpose of this article is to present the basic tenets of Lexipontix through an illustrative case report and to discuss potential mechanisms/processes underlying the program's effectiveness. Therefore, the first part of the article provides a succinct description of Lexipontix through the journey of Thomas (not his real name), a 10-year-old boy who stutters, and his family. In the second part, we aim to explore the mechanisms underlying the effectiveness of the program.

Case Study: Thomas

Thomas is a 10-year-old boy who stutters, referred to the third author's private practice by his parents. Thomas' parents decided to seek speech-language services for their son because they were very concerned about his stuttering, especially since they had noticed an increase in its frequency and severity the last few months. Thomas and his family live in a city in the mainland of Greece and the only spoken language at home is Greek.

Assessment

The Formulation Chart—Assessing Thomas' overall stuttering experience. The overall stuttering experience of Thomas and his family was assessed with the Lexipontix Assessment Protocol (LAP),[2] a protocol grounded in the International Classification System of Functioning, Disability, and Health (ICF) model[20] and its adaptation to stuttering.[21] The LAP provides the clinician with a systematic, yet dynamic and flexible, framework to assess the four interrelated components of the ICF model (body function, activity and participation, personal factors, and environmental factors) and subsequently maps the assessment results onto the Lexipontix Formulation Chart (see [Fig. 1]).

Figure 1 Lexipontix Formulation Chart.

Mapping data from the LAP into the Formulation Chart is a collaborative process that involves the child, the parents, and the therapist. Information collected during the assessment (e.g., child's reactions to stuttering) is shared with the family and evaluated in collaboration with them for its accuracy and importance for the child's and family's overall experience of stuttering. Consequently, the information is mapped on the Formulation Chart. This collaborative process enhances understanding and consensus about the child's stuttering experience, allows for the formulation of valid clinical hypotheses, and guides treatment planning and monitoring.

Assessment is conducted over three 90-minute sessions and includes a variety of assessment tools (formal and informal) and structured interviews (see Appendix A) that tap each of the ICF components. For example, the “Body Function” LAP involves the collection of data on speech fluency (e.g., percentage of syllables stuttered [%SS], duration of stuttered disfluencies, and concomitant behaviors), speech naturalness, and articulatory rate from different speech samples (e.g., conversation, narrative, expository discourse) and reading tasks. Also, children's temperament is assessed with parent- and self-report questionnaires, clinical observation, and parent interview. During the child and parent interviews, additional areas of assessment can emerge. For example, if Thomas' parents were concerned about his language skills, he would have undergone a comprehensive language assessment with a series of standardized and informal language tests. However, given the lack of parental concern, only a story retelling task was administered, and Thomas' language skills were judged to be typical for his age.

Thomas' Formulation Chart (see [Table 1]) summarizes and depicts Thomas' stuttering experience before the onset of therapy. Hence, it was used to inform clinical decisions regarding treatment goal setting, to monitor progress during therapy, and to evaluate post-treatment changes in Thomas' stuttering experience.

Table 1 Thomas' Formulation Chart

Formulation Chart: Thomas, 10;4 (years;months)
Body Function	Activity / Participation
Fluency: The most common disfluency is sound-syllable repetition. Prolongations and blocks are less frequent. • Percentage of syllables stuttered (%SS): Connected Speech = 7.3%, Reading = 17.6%. • Duration of stuttered disfluencies: Fleeting. • Concomitant behaviors: Grimaces, avoidance of eye-contact, leg jerks. • Naturalness of Speech: Good (on a scale poor/good/high). • Articulatory Rate: Average for age. Stuttering onset: At 4 years of age. Stuttering trajectory: Stuttering severity has increased in the last year. Genetics: Father and uncle stutter. Oral motor coordination: Mild difficulties. Language skills: Average language skills. Executive functioning: Low sustained attention, low auditory working memory, difficulties with organization. Temperament: Sensitive, introvert, high in negative affect, slightly rigid.	Home: Participates in everyday family conversations. Sociable with relatives, friends, and familiar people. Reluctant to answer the phone. Parental concerns regarding school achievement and impact of stuttering on his mental health. Education: Participates in class projects. Raises his hand in class to answer questions. Average-to-high academic achievement. Good relationships with classmates. Struggles with reading aloud in class but keeps trying. Struggles with classroom presentations. Peers: The children in the village where he spends some weekends and his summers, make comments about his speech. Older children at school have teased him for his speech. Social and Public Life: Finds it hard to talk to unfamiliar people. Finds it hard to talk in environments (e.g., shops) outside home and school. OASES-S: Section III: Daily Communication Score= 2.60 (Moderate Impact); Section IV: Quality of life Score= 2.22 (Mild-Moderate Impact). Palin PRS Factor 1: Impact of stuttering on the child: Mother's Score: 4.60 (moderate) & Father's Score: 5.97 (low).
Personal Factors	Environmental Factors
Cognitive: • CAT = 23 • Seems to be oversensitive to others' evaluation “Whenever I speak, I feel like I'm taking an exam”. Low self-confidence. Has a hard time acknowledging his abilities and strengths. • OASES-S: Section I: General Information Score = 3.46 (Moderate-Severe Impact) Emotional: • Reported feelings of anxiety, shame and sadness. • OASES-S Section II: Speaker's Reactions Score = 2.85 (Moderate impact). Behavioral: Hesitant to take initiative. Speaks quickly to avoid taking too much time away from his communication partner. Avoids words and situations (e.g., avoids answering the phone). Speaks openly about stuttering with his parents. Occasionally uses pauses as a strategy. Personal Information: Fifth grader. Learns English as a second language and takes swim lessons. Likes playing board-games. Claims autonomy and independence. Past Experiences: Has not received clinical services in the past. Teacher has been helpful and understanding.	Home Environment: Has a younger sister (8 years old). Father is currently unemployed and spends a lot of time at home. Father stutters and empathizes with Thomas. Parents are on the same page when it comes to parenting. Parents have high expectations of their children. They often provide Thomas with guidance in organizing his after-school activities such as homework and household chores (e.g., tidy up his bedroom). They do so by helping him break down tasks into small and manageable steps and providing frequent prompts and reminders. Parents are anxious about stuttering. They support fluency by talking slowly, giving time, and praising fluent speech. Family values: Diversity is a human right. Palin PRS: • Factor 2: The severity of stuttering and its impact on the parent: • Mother's Score: 2.11 (high) • Father's Score: 2.91 (moderate) • Factor 3: Parent's knowledge of stuttering and confidence in managing it: • Mother's Score: 5.14 (moderate) • Father's Score: 4.70 (moderate) Social Environment: Older children often tease Thomas when he stutters. Physical Environment: Family lives in an urban area and visits their summer home at a nearby village often. There is a fluency specialist where they live. Services - Organizations – Policies – Legislation: No speech therapy services at school. Health insurance covers outpatient speech-language therapy services for stuttering. Easy access to specialized stuttering services.

Abbreviations. CAT, Communication Attitude Test³⁶; OASES-S, Overall Assessment of the Speaker's Experience of Stuttering–School-Age²⁴; Palin PRS, Palin Parent Rating Scales.[25]

Eliciting “best hopes” and expectations from therapy. A key component of the LAP is the initial interview during which the clinician elicits the child's and the parents' “best hopes” and expectations from therapy through a SFBT conversation. The structured Family Interview Protocol used in Lexipontix can be found in Appendix B. Below is an excerpt from the family interview with Thomas and his parents.

Therapist: Imagine that today is our last session. What changes will you be pleased to notice that let you know that therapy was successful?

• Thomas: I will speak more easily and I will feel better while talking.

• Father: Thomas will speak more fluently, he will manage his stutter better, and he will be more confident.

• Therapist: And what differences will you be pleased to notice for you?

• Father: I will know what I can do to help my child.

• Therapist: What else?

• Father: I will be less anxious about his future.

• Therapist: And how about you, Lisa? (addressing the mother)

• Mother: Thomas will stutter less and stuttering will not be a big deal in his daily communication and life. For me, I will be reassured that he will not be hurt by other children's comments.

• Therapist: What will be another good outcome of our collaboration for you?

• Mother: I will be happier and more relaxed at home.

Eliciting expectations is not an easy task and the “best hopes” question may be asked many times, in different ways, to be understood and answered appropriately. Also, the follow-up “what else” question helps clients reveal less prominent expectations and expectations beyond those related to fluency. Following the “best hopes” questioning, the therapist asked Thomas and his parents to describe what difference the fulfillment of their expectations would make.

• Therapist: Thomas, suppose that your best hopes are fulfilled and everything you described has happened, that is, you speak more easily, and you feel better while talking. What difference would that make?

• Thomas: I would say what I wanted to say and my classmate Yannis would not laugh at me.

• Therapist: Lisa, suppose that your best hopes are fulfilled and everything you described has happened. What difference would that make?

• Mother: I will be relieved.

• Therapist: How about you Kostas?

• Father: I will be happy to know how to help Thomas.

The “what difference would that make…” question often elicits responses that help the child and the family consider therapy outcomes and expectations other than those directly related to speech. Clients often describe changes related to cognition, emotions, and behaviors, as well as changes related to the environment, everyday communication, activity and participation, and quality of life. They often say… “I will make new friends,” “I will read aloud in class without fear,” “I will feel confident,” “I will say what I want to say,” “I will know, as a parent, what I can do to help my child,” and “I will have less anxiety.”

The last question in the Family Interview Protocol of LAP is the following scaling question: “On a 0-10 rating scale, where 10 represents the fulfillment of all of your expectations and 0 represents the complete opposite, where are you now?” Thomas and his father answered they are at a 7 and his mother rated herself at a 6. By asking clients to elaborate on their answers, describe their competencies, and identify what they already do that contributes to the achievement of their best hopes, the discussion focuses on clients' past successes and reveals their strengths.

• Therapist: Thomas, what helps you be at a 7?

• Thomas: Sometimes I stop to think what I want to say and there are many times when I do not care how I talk.

Responses to the Family Interview Protocol questions demonstrated that, consistent with research findings,[22] [23] Thomas' and his parents' “best hopes” did not fully align. Overall, their expectations from therapy suggested desired changes in all ICF components, indicating the need for taking a holistic approach to therapy. Through the SFBT-style interview process, it was revealed that, at times, Thomas and his family utilized their resources to manage their challenges and difficulties successfully, and had already been doing things that helped them move toward meeting their expectations. Those moments of success were thoroughly described, explored, and exploited in the process of change.

Intervention

Both the findings of the comprehensive assessment, summarized in Thomas' Formulation Chart, and the information about Thomas' and his parents' expressed “best hopes” guided and informed the therapy goals grounded in the Lexipontix program described in the sections below.

General information about the Lexipontix program. Lexipontix introduces therapy as a role-play game based on a child-friendly theme. The main characters are the child in the role of a Superhero, who tries to defend his Factory of Mind, and a naughty mouse called Lexipontix. Lexipontix tries to invade the child's Factory of Mind and sabotage the Factory Machines. Empowered by his allies (parents, siblings, friends, significant others at home and school) and armed with tools (blue, red, and yellow tools) the child is involved in Missions and Experiments to deal with Lexipontix's mischievous activity. The Factory of Mind (see [Fig. 2]) is composed of four interrelated components (Machine of Thoughts, Laboratory of Emotions, Body Sensors, and Machine of Actions and Words) that work synergistically and correspond to the key elements of the CBT cycle (thoughts, emotions, somatic reactions, and behaviors).[4] [5] [6] The Factory of Mind is regulated by its central control panel, the Control Center, which constantly receives and sends information, keeping all factory components in equilibrium. Stuttering occurs when Lexipontix attempts to intrude in the Factory of Mind and sabotage any of the factory machines or the Control Center.

Figure 2 Factory of Mind.[3]

The child defends his Factory of Mind with blue, red, and yellow tools which, as mentioned in the previous section, include alliance tools, tools for thoughts and emotions, and speech tools, respectively. By introducing therapy as a role-play game based on a theme using child-friendly materials, enjoyable activities, and card games, Lexipontix personalizes therapy and makes therapy meaningful and fun. The child gradually experiences an informed, realistic, and harmonious relationship with his stuttering such that stuttering is not a worrying threat anymore.

At their post-therapy interview, parents and children are encouraged to share their experience with the Lexipontix program. For example, Thomas' father wrote the following: “Taking part in Lexipontix has been a unique experience. It offers a creative journey for the young and the old…. Activities involving card games and missions made the program adventurous and fun, and learning techniques interesting.” Thomas said: “I was born that way. Some people are born with a stutter. It is our right to stutter! …. My speech tools have become popular! My friends and allies ask me to teach them my speech tools. Actually, I have considered becoming a speech and language therapist when I grow up…. My speech will not be an issue for me as it was in the past.”

The structure of the Lexipontix program—Core and Modular components. The program develops in two phases, Phase A (see [Fig. 3]) and Phase B. Phase A lasts for 13 sessions toward the end of which (sessions 12 and 13) progress is assessed to determine if additional therapy (Phase B) is recommended. If no additional therapy sessions are needed, follow-up sessions are scheduled at 1, 3, 6, and 12 months post-treatment. Most children and parents experience significant changes by the end of Phase A and complete only the follow-up monitoring sessions, without needing additional therapy sessions.

Figure 3 The structure of the Lexipontix program.[3]

As shown in [Fig. 3], Phase A starts with the foundational/basic Core Structure (sessions 1–5) followed by the Modular Structure (sessions 6–11). The Core Structure is common across all the families enrolled in the program and, hence, is relatively fixed. However, the subsequent Modular Structure is composed of several modules (clinical tools) that allow for the therapy to be highly flexible, individualized, and easily tailored to the needs of each child and family. The modules to be activated in the Modular Structure are provisionally selected at the end of the assessment process, in collaboration with the clients. Across both the Core Structure and the Modular Structure, clinical tools and practices from PCI therapy[7] [8] (blue tools), CBT[4] [5] [6] (red tools), and Speech Restructuring[12] [13] [14] (i.e., fluency shaping and stuttering modification) (yellow tools) are incorporated. In Phase B, additional modules that share the same therapy principles are implemented.

Clinical decisions about the modules to include in Thomas' treatment plan were guided by the following principles. Modules were selected to (1) facilitate changes toward Thomas' and his parents' expectations; (2) achieve maximal change in the shortest amount of time, making optimal use of family resources; (3) utilize Thomas' internal and external resources to counterbalance the pressures on his fluency at different levels (e.g., linguistic, cognitive, and emotional); and (4) use personal and environmental resources to reduce environmental pressures. From the available modules (see [Fig. 3]), the modules selected for Thomas are shown in [Table 2] and described as follows:

Table 2 Modules Selected for Thomas' Modular Structure (Sessions 6–12)

Alliance strategies—blue tools

Alliance interaction strategies

Alliance empowering strategies

Recruitment of new allies

Teacher alliance

Cognitive behavioral therapy modules—red tools

Talking back

Negative automatic thought modifier (NAT-M)

Behavioral experiments

Voluntary stuttering (mouse walks)

Problem solving

Speech restructuring—yellow tools

Easy onset (airplane talk)

Pause (bus talk)

Note: Italicized terms in parentheses are child-friendly labels for the preceding tools/modules. They are used in therapy for learning purposes and for increasing understanding and keeping therapy engaging and fun.

Alliance Strategies: Blue Tools

Alliance interaction strategies (AISs): Thomas' parents were asked to establish a 5-minute daily “special times” routine[3] [8] during which they interacted with Thomas and implemented different strategies deemed to be helpful in reducing pressure on Thomas' fluency. For example, they were encouraged to practice AISs related to reducing their rate of speech (e.g., use of pauses) to help with Thomas' mild oral motor coordination difficulties and minimize communicative time pressure. In the Lexipontix program, these helpful interaction patterns are labeled as AISs and are tailored to the child's needs and the parents' expertise about what seems to help their child's fluency. Through practicing targeted AISs, parents are expected to increase their knowledge and confidence in managing their child's stuttering, which in turn can lead to reduction of their anxiety.

Alliance empowering strategies (AESs): The AESs are strategies whose goal is to strengthen parent–child communication and relationships. “Special time,” mentioned earlier, was one of the AESs that motivated collaboration between Thomas and his family. Another core AES introduced in Thomas' therapy and practiced by his parents was “praise.” Praise helped Thomas acknowledge his personal resources and individual “powers” and increased his self-confidence. In addition to the above AESs that are activated in the Core Structure, the “autonomy/internal locus of control” AES was activated in the Modular Structure. This AES was expected to help Thomas take more initiative in his everyday life and to facilitate the development of executive functions skills (e.g., organization skills). Thomas' increased autonomy (e.g., self-initiative) and internal locus of control (e.g., perceiving himself as able to face challenges) probably also helped balance the reported high parental expectations.

Recruitment of new allies: The recruitment of new allies module involves the child talking to others openly about his/her stuttering and therapy and recruiting allies (e.g., friends) to support his/her therapy goals. For example, allies are invited to participate in different therapy activities, such as practicing speech tools and engaging in CBT-style behavioral experiments with the child who stutters. Thomas already had a supportive network of friends to help counterbalance teasing. Also, it was deemed that his ability to make friends easily could help him expand his alliances, which in turn would bring about positive attitudinal changes for him and others in his environment. Furthermore, adopting an open attitude about stuttering, as addressed in this module, was expected to reduce societal pressures, stereotypes, and bullying behaviors, and increase assertiveness.

School alliance: Analogous to the recruitment of new allies module, the school alliance module entails inviting the teacher, other school staff members, and classmates into the alliance. This module was selected to create a supportive environment at school, strengthen the already formed alliance with the teachers, and inform Thomas' classmates and school staff about stuttering and Thomas' competence in dealing with it. Thomas' teacher had been an important ally, and it was expected that Thomas would maintain and increase his participation in class and experience less struggle when reading aloud.

CBT Modules: Red Tools

Identification of negative automatic thoughts (NATs) is a prerequisite skill for all the CBT tools used in the Lexipontix program. However, it is not an easy skill for school-age children, as it requires motivation, concentration, and self-reflection skills. Thus, card games targeting this skill have been carefully developed for Lexipontix. Thomas and his parents were trained to identify NATs using these card games and were assigned weekly identification tasks to notice NATs, (un)related to stuttering, in their everyday lives. They were provided a record form to document information related to the events that produced a NAT, and they were asked to bring this information to the session for discussion and elaboration. The recorded NATs were used to learn and practice red tools such as talking back and reframing of NATs. Thomas' parents were encouraged to identify, record, and discuss their own NATs in therapy too.

Talking back: The talking back module was incorporated into Thomas' therapy program to help him and his parents manage unhelpful thoughts and feelings. This module involves the person using rational arguments to confront a NAT that Lexipontix (the mouse) “plants” in the person's Factory of Mind. The confrontation takes the form of a debate between the person and Lexipontix. The side (Thomas or Lexipontix) with the strongest argument wins the debate. Starting at session five, Thomas and his family gradually learned to challenge their NATs by carrying out the talking back debate as an internal dialog when experiencing a NAT.

Negative automatic thought modifier (NAT-M): Practicing the NAT-M module, Thomas was taught to use a three-step process to reframe NATs: (1) identify the NAT Lexipontix had planted; (2) counterattack the identified NAT by providing alternative explanations or by finding alternative ways of thinking about or approaching a situation influenced by the NAT; and (3) modify the initial NAT into an alternative, empowering, helpful thought that made the most sense. The effectiveness of the NAT-M process is evaluated with a “worry scale meter” that compares the pre- and post-modification levels of anxiety caused by the NAT. Modifying/reframing NATs results in behavioral changes. For example, when Thomas was thinking “There is no way I can present my work in class. They will laugh at me,” he worried too much (an 8 out of 10 on the “worry scale meter”) and avoided participating. After practice, Thomas was able to challenge the NAT, “they will laugh at me,” and replace it with the more helpful thought: “I will use my airplane talk to keep moving forward. After all, it's my right to stutter.” As a result of practicing the NAT-M tool, Thomas reduced his anxiety level, depicted on the “worry scale meter” (now a 5) to a point that allowed for the meaningful behavioral change of presenting his work in class.

Behavioral experiments: This CBT module involves challenging unhelpful thoughts and beliefs through experimentation and hypothesis testing. In Thomas' therapy program, this module was activated to reconstrue Thomas' and his parents' irrational beliefs (e.g., “stuttering takes time away from my communication partners”) and unhelpful thoughts related to listener evaluations and reactions (e.g., “people are annoyed by my stuttering”).

Exposure (mouse walks): This module involves gradual exposure to stuttering in real-life situations by practicing voluntary stuttering. Τhis module was activated to enhance Thomas' and his parents' desensitization and counterbalance Thomas' oversensitivity to listeners' evaluations.

Speech Restructuring Tools: Yellow Tools

Pause (bus talk): One of the resources that Thomas brought to therapy was the occasional use of pauses in his speech as a self-help behavior. During therapy, this self-devised behavior was fine-tuned and evolved into a strategy, a personal fluency-enhancing technique used intentionally in situations where Thomas wished to achieve increased fluency. Thomas was encouraged to explore the difference that the use of pausing made to his communication. Reflecting on his experience of the use of pauses he commented: “I will pause before responding so I am setting a pace that works for me when I am communicating.”

Easy onset (airplane talk): During the assessment, Thomas expressed his wish to be able to better manage his speech when reading aloud in the class. To address Thomas' expressed goal, the optional module easy onset was incorporated in his treatment program to help him gain control over the initiation of voicing while in reading and, in turn, increase his confidence in reading aloud in class.

The aforementioned modules were selected at the onset of treatment, but small modifications were made over the course of Thomas' treatment based on the weekly feedback the clinician elicited from Thomas and his parents. This fine-tuning of goals after the onset of therapy through a collaborative process between the child who stutters, the family, and the clinician is an important component of the Lexipontix program. For example, Thomas was afraid to participate in mouse walks (i.e., practice voluntary stuttering in real-life situations) and he had expressed the accompanying unhelpful thought that other people would laugh at him. To help Thomas challenge this unhelpful thinking, the module behavioral experiments (described earlier), which had not been initially selected, was promptly introduced in Thomas' treatment plan.

Post-Intervention Evaluation

Post-intervention changes in Thomas' stuttering experience were evaluated during Session 12 toward the end of Phase A using some of the same assessment tools used at the initial assessment (see [Table 3]). This post-treatment evaluation session was followed by a 1-month consolidation period during which Thomas, his parents, and other members of Thomas' alliance (e.g., his sister and close friends from his school and his neighborhood) practiced the use of clinical tools in everyday life at home and in other settings. During the consolidation period, the family did not visit the clinic. After the consolidation period, Thomas and his parents visited the clinic (13th in-person visit) and were asked to describe the changes they had noticed as a result of the Lexipontix program therapy experience. The clinician used the Alliance Interview Protocol[2] specifically designed for this purpose. Some of the questions in the interview protocol are as follows:

• With 10 being “I am totally satisfied with my communication in everyday life” and 0 the complete opposite, what number represents your satisfaction with your communication in everyday life?

• Four months have passed since the beginning of the program. What is different?

• Of all the things we did during this period, which ones do you think yielded the changes you just described? (what else…?)

• When your satisfaction with communication in everyday life increases by one point on the 0 to 10 scale, how would you notice? What will you be doing differently?

• Are there times when you are already at this point? What is happening then?

Table 3 Thomas' Pre-therapy and Post-therapy Stuttering-related Measures

Measures	Pre-therapy	Post-therapy
%Syllables stuttered
Child interview	7. 3%	4. 1%
Parent–child interaction time	6. 7%	2. 2%
Story retelling task	8.3%	3.1%
Reading aloud	17.6%	5.3%
OASES-S
Section I. General information	3.46 (moderate-severe impact)	1.87 (mild-moderate impact)
Section II. Speaker's reactions	2.85 (moderate impact)	1.30 (mild impact)
Section III. Daily communication	2.60 (moderate impact)	1.13 (mild impact)
Section IV. Quality of life	2.22 (mild-moderate impact)	1.10 (mild impact)
Overall impact	2.82 (moderate impact)	1.33 (mild impact)
Behavioral assessment battery
CAT	23	12
Palin Parent Rating Scales
Impact on the child—Mother	4.60 (moderate)	6.75 (very low)
Impact on the child—Father	5.97 (low)	6.86 (very low)
Severity of stuttering and its impact of the parents—Mother	2.11 (high)	6.35 (very low)
Severity of stuttering and its impact of the parents—Father	2.91 (moderate)	6.43 (very low)
Parent's knowledge of stuttering and confidence in managing it—Mother	5.14 (moderate)	7.46 (very high)
Parent's knowledge of stuttering and confidence in managing it—Father	4.70 (moderate)	7.30 (very high)

Abbreviations: CAT, Communication Attitude Test[36]; OASES-S, Overall Assessment of the Speaker's Experience of Stuttering–School-Age[24]; Palin PRS, Palin Parent Rating Scales.[25]

Question (b) helped Thomas and his parents reflect and describe in detail all the changes they had noticed, and question (c) helped them make the connection between their achievements and the clinical tools they used. Question (d) helped them describe their immediate preferred future, whereas question (e) helped them realize that there are moments when they do things that bring their preferred future into reality.

In response to Question b, Thomas' parents said: “Thomas is not afraid to talk on the phone anymore. He has more courage and confidence. He is not afraid to talk in class regardless of whether he is using speech tools, and he is the one who initiates discussions about stuttering at school. Thomas is more responsible with tasks he has to complete, and he is better organized. He speaks more and he is involved in more conversations. He is confident and courageous even when he stutters.” Answering the same question Thomas said: “I can control my speech with techniques; I have better fluency in the classroom, during recess, and even at birthday parties. I feel more confident in reading aloud and my teacher praised me for participating more in class. I have a better relationship with my classmates and my friends trust me more. I can manage my difficulty in the best possible way.”

Thomas' father also remarked that: “…success was most evident when Thomas wished that the program had lasted longer and he asked to continue coming to therapy. The positive change in Thomas' speech and self-confidence exceeded our expectations, as he can now manage his stuttering experience, his environment as well as his future. Recruiting new allies and using Talking Back helped him communicate freely.” Mother noted that: “Therapy helped us work as a team. We discovered things about our child (concerns and difficulties) which had not been on our radar. At the same time, we also discovered strengths we didn't know he had. We learned what to do to help him appropriately with his stuttering. Our child seems happier after therapy.”

These reports demonstrate that Thomas' and his parents' expectations from therapy, as described in the assessment section, were largely fulfilled. Also, marked changes in Thomas' stuttering experience were evident when comparing his pre- and post-therapy assessment data (see [Table 3]).

Effectiveness of the Lexipontix Program

Research Evidence of the Effectiveness of the Lexipontix Program

Preliminary evidence for the effectiveness of the Lexipontix program was assessed using a retrospective chart review. The speech therapy records of 29 Greek-speaking school-age children who had completed Phase A of the Lexipontix program at the outpatient clinic of the first author were reviewed. Twenty-six of them had completed pre- and post-intervention data for the outcome measures of interest and were included in the study. The age range of the participants was 7;3 to 12;4 years (years;months) with an average age of 9;6 years (SD = 17.35 months). Treatment was implemented by four different speech-language therapists specializing in stuttering and trained in the Lexipontix protocol. The outcome measures of interest were: (1) stuttering frequency (%SS) based on a 300-word conversational sample and a reading sample, (2) clinician-rated stuttering severity on a 10-point rating scale using the same 300-word conversational sample and reading sample, (3) speech-associated communication attitudes measured by the Communication Attitude Test (CAT),[36] (4) impact of stuttering on the child measured by the Overall Assessment of the Speaker's Experience of Stuttering–School-Age (OASES-S),[24] and (5) parents' perception of the impact of stuttering on the child, the severity of stuttering and its impact on the parents, and their knowledge of stuttering and confidence in managing it were measured by the Palin Parent Rating Scales (Palin PRS).[25] Pre- and post-treatment data are presented in [Table 4]. It should be noted that the choice of the studied outcome measures was partially determined by the availability of data in the reviewed clinical records. For example, pre- and post-data on “best hopes” (e.g., 0–10 rating scale) were not available for all participants; therefore, although “best hopes” is a central piece of the program, data for this aspect of the program are not provided here.

Table 4 Means (M) and Standard Deviations (SD) for Pretreatment and Post-treatment Speech-related Measures and p-values for the Wilcoxon Signed-rank Tests

Measures	Pretreatment M (SD)	Post-treatment M (SD)	p
% SS—conversational speech sample	4.99 (3.73)	2.62 (1.87)	0.002[a]
% SS—reading sample	5.83 (5.77)	3.20 (2.61)	0.019
Stuttering severity (0–10 rating scale)—conversational speech sample	4.42 (3.92)	2.17 (1.31)	<0.001[a]
Stuttering severity (0–10 rating scale)—reading sample	3.68 (2.28)	2.32 (1.32)	0.004
CAT	15.77 (6.55)	10.68 (5.74)	<0.001[a]
OASES-S overall impact	2.46 (0.54)	1.88 (0.49)	<0.001[a]
Palin PRS factor 1: impact on the child—Mother	4.55 (1.25)	5.67 (0.97)	<0.001[a]
Palin PRS factor 1: impact on the child—Father	4.51 (1.16)	5.46 (1.01)	0.002[a]
Palin PRS factor 2: severity of stuttering and its impact on the parents—Mother	2.99 (1.41)	4.81 (1.44)	<0.001[a]
Palin PRS factor 2: severity of stuttering and its impact on the parents—Father	3.19 (1.35)	4.44 (1.27)	<0.001[a]
Palin PRS factor 3: parents' knowledge of stuttering and confidence in managing it—Mother	4.89 (1.64)	6.30 (1.26)	<0.001[a]
Palin PRS factor 3: parents' knowledge of stuttering and confidence in managing it—Father	4.53 (1.43)	6.14 (1.05)	<0.001[a]

Abbreviations: CAT, Communication Attitude Test[36]; OASES-S, Overall Assessment of the Speaker's Experience of Stuttering–School-Age[24]; Palin PRS, Palin Parent Rating Scales.[25]

^a Significance at the Bonferroni corrected level of significance (adjusted α = 0.004).

A series of nonparametric Wilcoxon's signed-rank tests were conducted, and the Bonferroni correction for multiple comparisons was applied, resulting in a significance level of p < 0.004. As shown in [Table 4], participants presented with a statistically significant decrease in stuttering frequency and stuttering severity in conversational speech. Furthermore, children's CAT and OASES-S scores were significantly reduced post-treatment, and both parent groups (mothers and fathers) reported significantly lower impact of stuttering on their child post-treatment. Also, parents' Palin PRS scores indicated a significant perceived decrease in their child's severity of stuttering and the impact of their child's stuttering on them (Palin PRS factor 2), as well as an increased knowledge about stuttering and confidence in managing it (Palin PRS factor 3).

Results from this retrospective chart review are supportive of the effectiveness of the Lexipontix program for school-age CWS and their parents. Significant changes were noted in all areas associated with the children's and the parents' stuttering experience, with changes in the children's attitudes toward communication, the impact of stuttering on the children and the parents, and the children's overall quality of life being among the more notable ones. In sum, although this chart review is limited, given the lack of a control group, the findings are encouraging and highlight the need for an experimental intervention study conducted by researchers unaffiliated with the program in the future.

Clinical Reflections on the Effectiveness of the Lexipontix Program

Lexipontix seems to facilitate significant changes in the overall stuttering experience for school-age CWS and their parents in a relatively short amount of time. In this final part of the article, we discuss potential processes and factors contributing to the effectiveness of the program.

One of the central tenets of the program is recognizing, valuing, activating, and empowering the expertise of the child who stutters and his/her family. The clinician's role is redefined from that of the “expert” professional to that of a professional continually engaging in a collaborative relationship with the child and family, recognizing that they are the experts in their stuttering and their life. This perspective for stuttering treatment allows for the activation of common factors[26] [27] [28] [29] [30] [31] (i.e., therapeutic relationship, extratherapeutic factors, technique, hope/expectancy) that account for the effectiveness of therapies, according to the common factors theory.[32] [33] [34]

The development of a therapeutic relationship that recognizes and employs the skills and abilities the client brings to therapy is at the epicenter of the therapeutic process. Furthermore, through a clinician–client collaborative process, clinicians explore the client's best hopes, expectations, and priorities for preferred outcomes, to refine and individualize the treatment protocol (e.g., choice of modules) accordingly. This program is intended to be an ongoing process. Quite often, clients' “best hopes” change over time as a result of the therapeutic process. For example, in the course of therapy, “fluency” tends to become less of a hope in comparison to effective communication, engaging with others more, or being able to challenge NATs. Eliciting clients' best hopes and facilitating the move toward them is one of the most important tenets of the Lexipontix program and one that undoubtedly activates the power of hope for a preferred future. Also, the Lexipontix program successfully combines effective/evidence-based clinical practices and techniques such as PCI,[7] [8] CBT,[4] [5] [6] and speech control techniques such as stuttering modification[13] [14] and fluency shaping.[12] Finally, important extratherapeutic factors (e.g., client's resources) are explored, acknowledged, and activated through this program. The children and their parents focus on solutions, explore their strengths, and discover how to best utilize their resources and build new alliances.

The effectiveness of the Lexipontix program is further reflected in its structure. It provides a clear framework for both assessment and treatment, supported with a detailed manual[2] [3] and accompanying clinical materials (e.g., interview protocol, card games, therapy materials for each module). This structure ensures replicability of the intervention and offers security and confidence to the clinician in implementing the program.

In Lexipontix, therapeutic work is based on the principles of the SFBT approach.[11] Right from the start, clients are encouraged to “keep one foot in acknowledgement and one in possibility.”[35] For example, information elicited during the assessment is discussed with the clients in a way that acknowledges challenges and reveals strengths (e.g., “You have a hard time when reading in front of the class when you block, and I'm wondering how you still manage to read the whole text?”). In therapy, SFBT-type questions help clients look for exceptions to the problem they are facing and focus on moments of success (e.g., effective communication, purposeful use of one of the Lexipontix tools, or completion of one of the therapy tasks). Also, rating scale questions are used to elicit, amplify, and reflect changes in strengths and resources.

Thus, in Lexipontix, an important active ingredient of therapy is the therapeutic relationship that therapists build with the clients, a relationship that encourages clients to explore and harness their resources and strengths. Furthermore, Lexipontix helps children and their families interact with therapy “materials” in a novel way, experiment, and create knowledge that enriches their understanding of their own stuttering experience. As a result of the therapy experience, children manage to reconstrue their communicative role, alter the definition of communicative success and failure, and respond in functional and meaningful ways to the demands of communicative events. For children and parents, Lexipontix introduces opportunities of altering their experience of stuttering. For clinicians, Lexipontix introduces a changed “mindset”—a different mindset, not a different set of tools.

No conflict of interest has been declared by the author(s).

Acknowledgments

We would like to thank Thomas and his parents for their contribution to this article. We would also like to thank all the children and their families who have participated in the Lexipontix program efficacy studies and for everything we have learned from them.

Disclosures

George Fourlas:

Financial disclosure: Royalty recipient, ownership interest, and intellectual property rights for the Lexipontix program. I have co-developed the Lexipontix program and co-authored the Lexipontix program for School-age Children Who Stutter manuals (Volume I, Assessment process; Volume II, Therapy), published in Greek by Konstantaras Medical Publications, Athens, Greece. In this article, we discuss concepts that are presented in greater detail in the manuals. Finally, I am compensated for conducting training workshops on the Lexipontix program. This relationship is ongoing.

Nonfinancial disclosure: No nonfinancial relationships.

Katerina Ntourou:

Financial disclosure: Salaried full-time employee at the University of Oklahoma Health Sciences Center.

Nonfinancial disclosure: No nonfinancial relationships.

Dimitris Marousos:

Financial disclosure: Royalty recipient, ownership interest, and intellectual property rights for the Lexipontix program. I have co-developed the Lexipontix program and co-authored the Lexipontix program for School-age Children Who Stutter manuals (Volume I, Assessment process; Volume II, Therapy), published in Greek by Konstantaras Medical Publications, Athens, Greece. In this article, we discuss concepts that are presented in greater detail in the manuals. Finally, I am compensated for conducting training workshops on the Lexipontix program. This relationship is ongoing.

Nonfinancial disclosure: No nonfinancial relationships.

• References

• 1 Fourlas G, Marousos D. A report on the development and clinical application of Lexipontix, a new therapy programme for school age CWS. Procedia Soc Behav Sci 2015; 193 (30) 92-107
• 2 Fourlas G, Marousos D. Lexipontix – Volume I: Assessment Process. Athens: Konstantaras – Medical Publications; 2018
• 3 Fourlas G, Marousos D. Lexipontix – Volume II: Therapy Manual. Athens: Konstantaras – Medical Publications; 2019
• 4 Beck AT. The Diagnosis and Management of Depression. University of Pennsylvania Press; 1967
• 5 Beck AT. Depression: Clinical, Experimental, and Theoretical Aspects. New York: Harper and Row; 1967 In: Beck AT. Depression: causes and treatment. University of Pennsylvania; 1970
• 6 Beck JS. Cognitive Therapy: Basics and Beyond. The Guilford Press; 1995
• 7 Eyberg SM. and Members of the Child Study Laboratory. PCIT Treatment Manual. Session Outlines. University of Florida; 1999
• 8 Kelman E, Nicholas A. Palin Parent-Child Interaction Therapy for Early Childhood Stammering. 2nd ed.. London: Routledge; 2020
• 9 Berg IK. Family Preservation: A Brief Therapy Workbook, Rev. ed. London: Brief Therapy Press; 1999
• 10 De Shazer S. Clues: Investigating Solutions in Brief Therapy. New York: Norton; 1988
• 11 De Shazer S, Dolan Y, Korman H. et al. More than Miracles: The State of the Art of Solution-Focused Therapy. Haworth Press; 2007
• 12 Ingham RJ, Andrews G. Behavior therapy and stuttering: a review. J Speech Hear Disord 1973; 38 (04) 405-441
• 13 Van Riper C. The Nature of Stuttering. Englewood Cliffs, N J. Prentice Hall; 1971
• 14 Van Riper C. The Treatment of Stuttering. Englewood Cliffs, NJ: Prentice Hall; 1973
• 15 Anderson H, Gehart D. Collaborative Therapy: Relationships and Conversations that Make a Difference. New York: Taylor and Frances Group; 2007
• 16 Biggart A, Cook F, Fry J. The role of parents in stuttering treatment from a Cognitive Behaviour Therapy perspective. Proceedings of the Fifth World Congress on Fluency Disorders. Dublin, Ireland; July 25–28, 2006: 268-375
• 17 Botterill W. Developing the therapeutic relationship: from ‘expert’ professional to ‘expert’ person who stutters. J Fluency Disord 2011; 36 (03) 158-173
• 18 Fry J, Cook F. Using cognitive therapy in group-work with young adults 2004. In: Packman A, Meltzer A, Peters HFM. eds. Proceedings of the Fourth World Congress on Fluency disorders. The Netherlands: Nijmegen University Press; 2003
• 19 Fry J, Farrants J. What's at stake? Adolescents' perceptions of the consequences of stuttering. In: Baker KL, Rowley D. eds. Proceedings of the Fourth World Congress on Fluency disorders. The Netherlands: Nijmegen University Press; 2003
• 20 World Health Organization. International Classification of Functioning, Disability, and Health. Geneva: WHO; 2001
• 21 Yaruss JS, Quesal RW. Stuttering and the international classification of functioning, disability and health (ICF): an update. J Commun Disord 2004; 37 (01) 35-52
• 22 Berquez A, Hertsberg N, Hollister J, Zebrowski P, Millard S. What do children who stutter and their parents expect from therapy and are their hopes aligned?. Procedia Soc Behav Sci 2015; 193: 25-36
• 23 Rodgers N, Berquez A, Hollister J, Zebrowski P. Using solution-focused principles with older children who stutter and their parents to elicit perspectives of therapeutic change. Perspect ASHA Spec Interest Groups 2020; 5 (06) 1427-1440
• 24 Yaruss GJ, Quesal RW. Overall Assessment of the Speaker's Experience of Stuttering. McKinney: Stuttering Therapy Resources, Inc.; 2016
• 25 Millard SK, Davis S. The Palin Parent Rating Scales: parents' perspectives of childhood stuttering and its impact. J Speech Lang Hear Res 2016; 59 (05) 950-963
• 26 Assay TP, Lambert MJ. The empirical case for the common factors in therapy: quantitative findings. In: Hubble MA, Duncan BL, Miller SD. eds. The Heart and Soul of Change: What Works in Therapy. Washington, DC: American Psychological Association; 1999: 33-56
• 27 Bernstein Ratner N. Evidence-based practice in stuttering: some questions to consider. J Fluency Disord 2005; 30 (03) 163-188
• 28 Franken MC, Kielstra-Van der Schalk CJ, Boelens H. Experimental treatment of early stuttering: a preliminary study. J Fluency Disord 2005; 30 (03) 189-199
• 29 Hubble MA, Duncan BL, Miller SD. The Heart and Soul of Change: What Works in Therapy?. Washington, DC: American Psychological Association; 1999
• 310 Lambert MJ, Bergin AE. Therapist characteristics and their contribution to psychotherapy outcome. In: Bergin AE, Garfield SL. eds. Handbook of Psychotherapy and Behavior Change, 4th ed. New York: John Wiley & Sons, Inc.; 1994
• 31 Miller SD, Duncan BL, Hubble MA. Escape from Babel: Toward a Unifying Language for Psychotherapy Practice. New York: Norton; 1997
• 32 Herder C, Howard C, Nye C, Vanryckeghem M. Effectiveness of behavioral stuttering treatment: a systematic review and meta-analysis. Contemp Issues Commun Sci Disord 2006; 3: 76-81
• 33 Law J, Garrett Z, Nye C. The efficacy of treatment for children with developmental speech and language delay/disorder: a meta-analysis. J Speech Lang Hear Res 2004; 47 (04) 924-943
• 34 Zebrowski PM. Treatment factors that influence therapy outcomes of children who stutter. In: Conture E, Curlee R. eds. Stuttering and Related Disorders of Fluency, 3rd ed. New York: Thieme; 2007
• 35 O'Hanlon B, Beadle S. A Field Guide to Possibility Land. London: Brief Therapy Press; 1996
• 36 Brutten GJ, Vanryckeghem M. Behavior Assessment Battery for School-Age Children Who Stutter (BAB). San Diego, CA: Plural; 2007

Publication History

Article published online:
13 June 2022