Transcript Management of Early Childhood Stammering

The Michael Palin Centre:
Palin Parent Child Interaction Therapy
Elaine Kelman
The Michael Palin Centre for Stammering Children
Finsbury Health Centre, Pine St, London EC1R OLP
Telephone: 0207 530 4238
[email protected]
The Michael Palin Centre for
Stammering Children
London, England
Staff
11 specialist speech & language therapists
Business manager
2 administrative assistants
The Michael Palin Centre for
Stammering Children

Provides specialist assessment and therapy for
children, teenagers and adults who stammer

Funded by Association for Research into Stammering
in Childhood and NHS Islington
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Training programme for speech & language
therapists in UK and worldwide
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Research the nature of stammering and the
effectiveness of therapy
Training programme
2 or 3 day training courses in
 Palin Parent-Child Interaction Therapy
(under 7s)
 Family interaction (7 – 14s)
 Working with teenagers
 Direct fluency skills
 Cognitive Behaviour Therapy
 Solution Focused Brief Therapy
continued
Trainee programme
One to four weeks at the Michael
Palin Centre
Individually tailored to trainee’s needs
 Clinical supervision

The Michael Palin Centre website:
www.stammeringcentre.org
Oxford Dysfluency
Conference
September 1st to 4th 2011
St Catherine’s College, Oxford
Keynote speakers:
Nan Bernstein Ratner
Martin Sommer
Joe Donaher
Willie Botterill
Ann Packman
The Multifactorial Model
Physiological
factors
Speech and
language
factors
Stammering
Psychological
factors
Environmental
factors
A Multifactorial Framework
Predisposing physiological and linguistic factors
may be significant in the onset and
development of stammering
These predisposing factors interact with
emotional and environmental aspects and
contribute to severity, persistence and impact
on child and family
Importance of comprehensive
assessment
Assessment should include
 Speech and language skills (at all ages)
 Fluency assessment, including thoughts
& feelings about stammer & its impact
on the child & family
Aims of assessment
To determine the factors that contribute
to the onset and development of
stammering
 To identify the child’s vulnerability to
persistence
 To identify the appropriate care pathway
 To identify components of individually
tailored treatment programme

Factors associated with
recovery and persistence

Family history of stammering
 Gender
 Age at onset
 Length of time since onset
 Pattern of change in stammering over time
 Phonological skills
 Language skills
 Severity of stammering
 Parental/child concern
NB Severity and frequency of stammering symptoms do not
correlate with risk of persistence
Assessment of parent child
interaction

Based on summary of findings from
child assessment

Consider what the child needs to help
his fluency

Identify what parents are already doing
that is helpful ie instinctive responses

Identify what parents may need to be
doing more of
Interaction Strategies
Evidence
of
Interaction Strategies
Potential target
Helpful
Mother
Father
Mother
Father
Following child's lead in play
Letting child solve problems
More comments than questions
Complexity of questions at child's level
Language is appropriate to child's level
Language is semantically contingent on child's focus
Repetition, expansion rephrasing
Time to initiate, respond, finish
Rate of input when compared to child's rate
Use of pausing
Using eye contact, position, touch, humour &/or surprise
Praise and encouragement
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Psychological/counselling
approaches which have influenced
the Michael Palin Centre
Behaviour therapy
 Family Systems Theory (Epstein and Bishop, 1981)
 Personal Construct Psychology (Fransella, 1972;

Kelly, 1955)

Solution Focussed Brief Therapy (DeShazer ,
1988; 1996; O’Hanlon and Weiner-Davis, 1989)

Cognitive Behaviour Therapy (Beck, 1995)
Michael Palin Centre Philosophy
1.
2.
3.
The children and
their parents are the
experts
It is not the parents’
fault
Children and
parents are already
doing helpful things
1. The children and their
parents are the experts

Our aim is to help them access and
build on their knowledge and skills

They already know

We don’t need to tell them
2. It is not the parents’ fault

Parents of children who stammer are no
different from parents of children who do not
stammer
 The child who stammers may not be able to
cope with typical interaction styles
3. Children and parents are
already doing helpful things
So we need to develop:
 their confidence in their own knowledge
and skills
 their skills in order to equip and
empower them
 their independence of the therapist to
increase their self-reliance
Therapeutic style
Collaborative
 Role as facilitator and reinforcer
 Who is the expert?
 Facilitating vs teaching or instructing
 Asking questions vs telling

Michael Palin Centre Style

Asking not telling
 Finding not
showing
 Focusing on the
positive
- child’s and
parents’ expertise
Involvement of the family system
Difficulties of transferring fluency from
the clinic to the real world
 Child changes
family changes
 Parents can be the vehicle of change

Use of video
Video is used throughout assessment and
therapy
 Outcome measurement
 Helps child & parents to be objective
about selves – develops autonomy
 Desensitisation
 Provides feedback about strengths and
progress
MPC therapy approaches
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Palin Parent Child Interaction Therapy
Lidcombe Programme
Other direct fluency programmes for young
children
Family Interaction Therapy
Integrated fluency shaping and speech
modification therapy
Cognitive Behaviour Therapy
Solution Focused Brief Therapy
Personal Construct Psychology
Delivery

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
Individual therapy (child + parents/carers)
Home programme
Group therapy (when children need more
fluency input or desensitisation) + parents’
groups
 Intensive group therapy (2-week, 10-14 years
+ parents, 15+years) with 1 year follow up
 Weekly term-time groups
 All based on initial and on-going assessment
of need and suitability
Palin Parent Child
Interaction Therapy
Palin PCI
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Summary Chart
Child's Name: ………………………………………………………
Date: …………………………………
Stammering & Social Communication Skills
% ss
%Time since onset
%Child's awareness/concern
Parent rating
Type of stammering
WWR PWR Prol.
< 6mths
%Pattern of change
Better
<12mths
Same
Blocking
Talking at length/turn taking
>12mths
Reduced eye contact
Reduced concentration
Worse
%Parents' levels of concern
Linguistic
% History of delayed speech/language development
% Reduced receptive skills
Physiological
%Family history of stammering
% Reduced expressive skills
Coordination
Word finding difficulty
Tiredness
% Speech sound difficulty
Birth history
% Advanced language skills
Health
Mismatch within/between speech/language skills
Rapid bursts/rate of speech
Managing two languages
Psychological
Environmental
Reduced confidence
Turn-taking in family
High standards
Behaviour management
Increased sensitivity
Routines
Anxious/worrier
Openness about stammering
Difficulties coping with change
Preschool/school issues
Reaction to stammering
Pace of life
What does this child need?
1
2
3
Evidence
Interaction Strategies
of
Potential target
Family Strategies
Helpful
Mother
Father
Mother
Child Strategies
Father
Following child's lead in play
Special Times
Rate reduction
Letting child solve problems
Managing two languages
Pausing to think
More comments than questions
Openness about stammering
Easy onset
Complexity of questions at child's level
Building confidence
Being more concise
Language is appropriate to child's level
Turn-taking
Eye contact/focus of attention
Language is semantically contingent on child's focus
Dealing with feelings
Other
Repetition, expansion rephrasing
High standards
Language/phonology therapy
Time to initiate, respond, finish
Sleep
School/preschool liaison
Rate of input when compared to child's rate
Behaviour management
Onward referral
Use of pausing
Routines
Using eye contact, position, touch, humour &/or surprise
Pace of life
Praise and encouragement
Emerging issues
28
Principles underlying Palin PCI
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Palin PCI focuses on parents’ intuitive
understanding and develops this in order to
facilitate the child’s natural fluency
One change in interaction triggers others
Stammering is heterogeneous, therapy needs
to be individually tailored
Interaction is a two way process
Therapy is collaborative
Therapist’s role is one of facilitator and
reinforcer
Feedback focuses on strengths
29
The Palin PCI therapy programme has 3 main
strands:
 Interaction strategies
 Family strategies
 Child strategies
30
Interaction Strategies
Interaction Strategies
Following child's lead in play
Letting child solve problems
More comments than questions
Complexity of questions at child's level
Language is appropriate to child's level
Language is semantically contingent on child's focus
Repetition, expansion rephrasing
Time to initiate, respond, finish
Rate of input when compared to child's rate
Use of pausing
Using eye contact, position, touch, humour &/or surprise
Praise and encouragement
31
Family Strategies
Family Strategies
Special Times
Managing two languages
Openness about stammering
Building confidence
Turn-taking
Dealing with feelings
High standards
Sleep
Behaviour management
Routines
Pace of life
Emerging issues
32
Child Strategies
Child Strategies
Rate reduction
Pausing to think
Easy onset
Being more concise
Eye contact/focus of attention
33
Other strategies
Other
Language/phonology therapy
School/preschool liaison
Onward referral
34
Interaction research
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Parents of children who stammer are viewed as interacting
with their child in ways that support his fluency
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Parents of children who stammer are not regarded as being
different from parents of children who do not stammer in
terms of their interaction style
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Parental interaction styles can be modified
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Changes in interaction style can increase fluency
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Stammering can influence parents’ interaction style
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Underlying vulnerabilities that predispose a child to stammer
make it more difficult for him to be fluent in the context of
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typical adult-child interactions
Overview of Palin PCI
Six weeks PCI
 Once per week
 With both parents/carers and child
 One hour sessions
 Six weeks Consolidation Period
 Review session
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Session 1
Set up Special Times
 5 minutes only
 Child chooses activity
 What to avoid: books, boisterous play,
TV, computer
 After Special Time is completed, return
to the activity if desired
 Offer Special Times to siblings
37
Session Two
Review of Special Times
 Discuss the child’s abilities and vulnerabilities
and what might help
 Watch PCI video
 Ask parent to notice what they are already
doing to help their child’s fluency
 Discuss how a particular strategy might be
helping their child’s fluency
 Agree a strategy that they will try to do more
of
 Give family strategy handout
38

Further sessions
Review of Special Times
 Watch PCI video
 Video feedback:
– what they are doing that is helping the
child’s fluency
– positive effects
 Identify new target & rationale
 Discuss family strategy
 Give family strategy handout
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Consolidation Period
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6 weeks with no clinic visits
Parents continue Special Times & complete sheets
Continue to praise & complete Praise Log
Continue other family strategies e.g. turn taking,
bedtimes, behaviour management
Parents send in completed sheets to therapist
Therapist monitors and makes contact as
necessary
Predict possible relapse
Parents encouraged to contact therapist if fluency
gets worse
Review appointment arranged at end of 6 weeks
40
Review appointment

At end of 6 week Consolidation Period
 Clinical outcome measures:
 Decision making
– Ongoing monitoring for at least 1 year
– Parents encouraged to contact therapist if fluency
worsens
– Further input: child strategies
41
Speech modification
Strategies:
 Tortoise talking – rate reduction (based on
Meyers & Woodford, 1992)
Bus talking – pausing to think
 Aeroplane talking – use of gradual
onset to speech
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Format of sessions
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Introduce the concept
Introduce the characters in a story
Identification activity
Production of strategy at single word level
Increase length of sentence
Practice in free play or general conversation
Generalisation and reinforcement Involve parent
in session and at home
Home practice
Praise child when he uses his strategy
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Video observation of SLT
Note the questions that the therapist is
asking
 Note any other observations about the
therapist’s style
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Role play – questions to ask
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What have we found out about why your child stammers?
(when does he stammer more?)
(what seems to affect his fluency?)
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What do you think he needs to do to be more fluent?

What are you already doing to help him to be more fluent
(What do you do or say to help him when he is stammering?)
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When are you doing that on the video?
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But what if…………….?
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What are the benefits of using
this style with parents?
What parents have said
“In the therapy the use of cameras and
feedback was fascinating and it was
nice to hear about what we did that was
positive, as well as what we could do to
help Holly”.
(Mother of Holly, aged five)
51
What parents have said
“From the outset the therapist gave us a
very clear explanation of how the therapy
was structured and what each step was
designed to achieve. That approach gave
us a level of understanding that enabled us
to feel empowered and incredibly positive
about the therapy”.
(Mother of Kai, aged seven)
52
What therapists have said
“I do lots of PCI work and now tend to focus on
increasing what they are doing well rather than
focusing on what is not going well”.
“I feel as if I listen to parents more and encourage
them to come up with the targets therefore
empowering them”.
“I am more aware of listening to parents and
facilitating discussion rather than leading it”
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Palin Parent Child Interaction
Therapy: the manual
Effectiveness of Palin PCI:
2 multiple single subject studies
Children at high risk of persistent
stammering (stammering >12 months)
 Age 2 – 5 years at start of study
 No therapy in previous 6 months
 English as main language at home
 No identified learning difficulties,
disorders or syndromes
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Design
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Percentage stammering data obtained
through video recordings of child playing at
home with parents
 Made once a week for 6 weeks prior to
therapy and 12 weeks during therapy (clinic
and home based)
 Study A (N=6) – recordings made once a
month for 12 months post therapy
(Millard, Nicholas & Cook, 2008)
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Study B (N=6) – recordings made once a
week for six weeks prior to 6 month review
Results
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8/12 participants significantly reduced
stammering during the therapy phase
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Other 4 reduced stammering over the period
of the studies
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10/12 participants discharged having only
received indirect component of Palin PCI
(interaction and family strategies)
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Children with advanced language skills
reduced expressive language scores (RDLS3) to within normal limits (Study B)
Results continued………..
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There was no change in receptive language
scores (Study B)
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Parents made changes to conversational
style and maintained these for a minimum of
3 months (Study A: Nicholas, Millard and Cook, 2003)
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Parents of children who received treatment
rated themselves as being less worried and
anxious about stuttering, and more
knowledgeable and confident in managing
stuttering (Study B)
Summary
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Importance of client-therapist relationship in
therapy outcome
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Palin PCI: Parents’ intuitive understanding
No different to parents of children
who do not stammer
Focus on strengths
Asking not telling
Eliciting not teaching
Finding not showing
59
References
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Kelman, E. & Nicholas, A. (2008). Practical
Intervention for Early Childhood Stammering: Palin
PCI Approach. Speechmark Publishing Ltd: Milton
Keynes, UK.
Millard, S.K., Edwards, S. & Cook, F. (2009) Parentchild interaction therapy: Adding to the evidence.
International Journal of Speech & language Pathology,
Vol 11. Issue 1. pp 61-76.
Millard, S.K., Nicholas, A. & Cook, F.M. (2008). ‘Is
Parent-Child Interaction Therapy Effective in Reducing
Stuttering?’ Journal of Speech, Language and Hearing
Research, 51(3), pp 636-650.