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: [phone] [e-mail]

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The Michael Palin CentrePalin Parent
Child Interaction TherapyElaine KelmanThe
Michael Palin Centre for Stammering
ChildrenFinsbury Health Centre, Pine St, London
EC1R OLPTelephone 0207 530 4238
elaine.kelman_at_islingtonpct.nhs.uk
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The Michael Palin Centre for Stammering
Children London, England
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Staff

• 11 specialist speech language therapists
• Business manager
• 2 administrative assistants

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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
• Training programme for speech language
  therapists in UK and worldwide
• Research the nature of stammering and the
  effectiveness of therapy

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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

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continued

• Trainee programme
• One to four weeks at the Michael Palin Centre
• Individually tailored to trainees needs
• Clinical supervision

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The Michael Palin Centre websitewww.stammeringce
ntre.org
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Oxford Dysfluency Conference

• September 1st to 4th 2011
• St Catherines College, Oxford
• Keynote speakers
• Nan Bernstein Ratner
• Martin Sommer
• Joe Donaher
• Willie Botterill
• Ann Packman

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The Multifactorial Model
Speech and language factors
Physiological factors
Environmental factors
Psychological factors
Stammering
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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

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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

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Aims of assessment

• To determine the factors that contribute to the
  onset and development of stammering
• To identify the childs vulnerability to
  persistence
• To identify the appropriate care pathway
• To identify components of individually tailored
  treatment programme

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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

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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

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Interaction Strategies
Interaction Strategies Helpful Evidence of Evidence of Potential target Potential target
Interaction Strategies 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 OHanlon and Weiner-Davis, 1989)
• Cognitive Behaviour Therapy (Beck, 1995)

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Michael Palin Centre Philosophy

• The children and their parents are the experts
• It is not the parents fault
• Children and parents are already doing helpful
  things

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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 dont need to tell them

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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

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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

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Therapeutic style

• Collaborative
• Role as facilitator and reinforcer
• Who is the expert?
• Facilitating vs teaching or instructing
• Asking questions vs telling

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Michael Palin Centre Style

• Asking not telling
• Finding not showing
• Focusing on the positive
• - childs and parents expertise

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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

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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

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MPC therapy approaches

• 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

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Delivery

• 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, 15years) with 1 year follow up
• Weekly term-time groups
• All based on initial and on-going assessment of
  need and suitability

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Palin Parent Child Interaction Therapy
Palin PCI
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Summary Chart Summary Chart Summary Chart Summary Chart Summary Chart Summary Chart Summary Chart Summary Chart Summary Chart Summary Chart Summary Chart Summary Chart Summary Chart Summary Chart Summary Chart Summary Chart
Child's Name Child's Name Child's Name Child's Name Child's Name Child's Name Child's Name Child's Name Child's Name Date Date
Stammering Social Communication Skills Stammering Social Communication Skills Stammering Social Communication Skills Stammering Social Communication Skills Stammering Social Communication Skills Stammering Social Communication Skills Stammering Social Communication Skills Stammering Social Communication Skills Stammering Social Communication Skills Stammering Social Communication Skills Stammering Social Communication Skills Stammering Social Communication Skills Stammering Social Communication Skills Stammering Social Communication Skills Stammering Social Communication Skills Stammering Social Communication Skills
ss Parent rating ss Parent rating ss Parent rating ss Parent rating ss Parent rating ss Parent rating ss Parent rating ss Parent rating   Child's awareness/concern Child's awareness/concern Child's awareness/concern Child's awareness/concern Child's awareness/concern Child's awareness/concern  
Type of stammering WWR PWR Prol. Blocking Type of stammering WWR PWR Prol. Blocking Type of stammering WWR PWR Prol. Blocking Type of stammering WWR PWR Prol. Blocking Type of stammering WWR PWR Prol. Blocking Type of stammering WWR PWR Prol. Blocking Type of stammering WWR PWR Prol. Blocking Type of stammering WWR PWR Prol. Blocking   Talking at length/turn taking Talking at length/turn taking Talking at length/turn taking Talking at length/turn taking Talking at length/turn taking Talking at length/turn taking  
Time since onset lt 6mths lt12mths gt12mths Time since onset lt 6mths lt12mths gt12mths Time since onset lt 6mths lt12mths gt12mths Time since onset lt 6mths lt12mths gt12mths Time since onset lt 6mths lt12mths gt12mths Time since onset lt 6mths lt12mths gt12mths Time since onset lt 6mths lt12mths gt12mths Time since onset lt 6mths lt12mths gt12mths   Reduced eye contact Reduced eye contact Reduced eye contact Reduced eye contact Reduced eye contact    
Pattern of change Better Same Worse               Reduced concentration Reduced concentration Reduced concentration Reduced concentration Reduced concentration    
Parents' levels of concern Parents' levels of concern Parents' levels of concern Parents' levels of concern Parents' levels of concern Parents' levels of concern Parents' levels of concern Parents' levels of concern   Linguistic Linguistic Linguistic Linguistic Linguistic Linguistic Linguistic
History of delayed speech/language development History of delayed speech/language development History of delayed speech/language development History of delayed speech/language development History of delayed speech/language development History of delayed speech/language development  
Physiological Physiological Physiological Physiological Physiological Physiological Physiological Physiological Physiological Reduced receptive skills Reduced receptive skills Reduced receptive skills Reduced receptive skills Reduced receptive skills Reduced receptive skills  
Family history of stammering                 Reduced expressive skills Reduced expressive skills Reduced expressive skills Reduced expressive skills Reduced expressive skills Reduced expressive skills  
Coordination                 Word finding difficulty Word finding difficulty Word finding difficulty Word finding difficulty Word finding difficulty Word finding difficulty  
Tiredness                 Speech sound difficulty Speech sound difficulty Speech sound difficulty Speech sound difficulty Speech sound difficulty Speech sound difficulty  
Birth history                 Advanced language skills Advanced language skills Advanced language skills Advanced language skills Advanced language skills Advanced language skills  
Health                 Mismatch within/between speech/language skills Mismatch within/between speech/language skills Mismatch within/between speech/language skills Mismatch within/between speech/language skills Mismatch within/between speech/language skills Mismatch within/between speech/language skills  
Rapid bursts/rate of speech Rapid bursts/rate of speech               Managing two languages Managing two languages Managing two languages Managing two languages Managing two languages Managing two languages  
Psychological Psychological Psychological Psychological Psychological Psychological Psychological Psychological Psychological Environmental Environmental Environmental Environmental Environmental Environmental Environmental
Reduced confidence                 Turn-taking in family Turn-taking in family Turn-taking in family Turn-taking in family Turn-taking in family    
High standards                 Behaviour management Behaviour management Behaviour management Behaviour management Behaviour management Behaviour management  
Increased sensitivity                 Routines Routines Routines        
Anxious/worrier Anxious/worrier Anxious/worrier Anxious/worrier Anxious/worrier Anxious/worrier Anxious/worrier Anxious/worrier   Openness about stammering Openness about stammering Openness about stammering Openness about stammering Openness about stammering Openness about stammering  
Difficulties coping with change Difficulties coping with change               Preschool/school issues Preschool/school issues Preschool/school issues Preschool/school issues Preschool/school issues Preschool/school issues  
Reaction to stammering                 Pace of life Pace of life Pace of life Pace of life Pace of life Pace of life  

What does this child need? What does this child need? What does this child need? What does this child need? What does this child need? What does this child need? What does this child need? What does this child need? What does this child need? What does this child need? What does this child need? What does this child need? What does this child need? What does this child need? What does this child need? What does this child need?
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Interaction Strategies Interaction Strategies Interaction Strategies Helpful Evidence of Evidence of Potential target Potential target Family Strategies Family Strategies Family Strategies Family Strategies Family Strategies Family Strategies Child Strategies Child Strategies
Interaction Strategies Interaction Strategies Interaction Strategies Helpful Mother Father Mother Father Family Strategies Family Strategies Family Strategies Family Strategies Family Strategies Family Strategies Child Strategies Child Strategies
Following child's lead in play Following child's lead in play Following child's lead in play           Special Times Special Times Special Times Special Times Special Times   Rate reduction  
Letting child solve problems Letting child solve problems Letting child solve problems           Managing two languages Managing two languages Managing two languages Managing two languages Managing two languages   Pausing to think  
More comments than questions More comments than questions More comments than questions           Openness about stammering Openness about stammering Openness about stammering Openness about stammering Openness about stammering   Easy onset  
Complexity of questions at child's level Complexity of questions at child's level Complexity of questions at child's level           Building confidence Building confidence Building confidence Building confidence Building confidence   Being more concise  
Language is appropriate to child's level Language is appropriate to child's level Language is appropriate to child's level           Turn-taking Turn-taking Turn-taking Turn-taking Turn-taking   Eye contact/focus of attention  
Language is semantically contingent on child's focus Language is semantically contingent on child's focus Language is semantically contingent on child's focus           Dealing with feelings Dealing with feelings Dealing with feelings Dealing with feelings Dealing with feelings   Other Other
Repetition, expansion rephrasing Repetition, expansion rephrasing Repetition, expansion rephrasing           High standards High standards High standards High standards High standards   Language/phonology therapy  
Time to initiate, respond, finish Time to initiate, respond, finish Time to initiate, respond, finish           Sleep Sleep Sleep Sleep Sleep   School/preschool liaison  
Rate of input when compared to child's rate Rate of input when compared to child's rate Rate of input when compared to child's rate           Behaviour management Behaviour management Behaviour management Behaviour management Behaviour management   Onward referral  
Use of pausing Use of pausing Use of pausing           Routines Routines Routines Routines Routines  
Using eye contact, position, touch, humour /or surprise Using eye contact, position, touch, humour /or surprise Using eye contact, position, touch, humour /or surprise           Pace of life Pace of life Pace of life Pace of life Pace of life  
Praise and encouragement Praise and encouragement Praise and encouragement           Emerging issues Emerging issues Emerging issues Emerging issues Emerging issues  
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Principles underlying Palin PCI

• Palin PCI focuses on parents intuitive
  understanding and develops this in order to
  facilitate the childs 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
• Therapists role is one of facilitator and
  reinforcer
• Feedback focuses on strengths

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• The Palin PCI therapy programme has 3 main
  strands
• Interaction strategies
• Family strategies
• Child strategies

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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
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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
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Child Strategies
Child Strategies
Rate reduction
Pausing to think
Easy onset
Being more concise
Eye contact/focus of attention
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Other strategies
Other
Language/phonology therapy
School/preschool liaison
Onward referral
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Interaction research

• Parents of children who stammer are viewed as
  interacting with their child in ways that support
  his fluency
• 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
• Parental interaction styles can be modified
• Changes in interaction style can increase fluency
• Stammering can influence parents interaction
  style
• Underlying vulnerabilities that predispose a
  child to stammer make it more difficult for him
  to be fluent in the context of typical
  adult-child interactions

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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

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Session Two

• Review of Special Times
• Discuss the childs abilities and vulnerabilities
  and what might help
• Watch PCI video
• Ask parent to notice what they are already doing
  to help their childs fluency
• Discuss how a particular strategy might be
  helping their childs fluency
• Agree a strategy that they will try to do more of
• Give family strategy handout

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Further sessions

• Review of Special Times
• Watch PCI video
• Video feedback
• what they are doing that is helping the childs
  fluency
• positive effects
• Identify new target rationale
• Discuss family strategy
• Give family strategy handout

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Consolidation Period

• 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

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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

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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

• 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 therapists
  style

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Role play questions to ask

• What have we found out about why your child
  stammers?
• (when does he stammer more?)
• (what seems to affect his fluency?)
• 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?)
• 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?
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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)

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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)

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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
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Effectiveness of Palin PCI 2 multiple single
subject studies

• Children at high risk of persistent stammering
  (stammering gt12 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

• 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 (N6) recordings made once a month for
  12 months post therapy
• (Millard, Nicholas Cook, 2008)
• Study B (N6) recordings made once a week for
  six weeks prior to 6 month review

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Results

• 8/12 participants significantly reduced
  stammering during the therapy phase
• Other 4 reduced stammering over the period of the
  studies
• 10/12 participants discharged having only
  received indirect component of Palin PCI
  (interaction and family strategies)
• Children with advanced language skills reduced
  expressive language scores (RDLS-3) to within
  normal limits (Study B)

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Results continued..

• There was no change in receptive language scores
  (Study B)
• Parents made changes to conversational style and
  maintained these for a minimum of 3 months (Study
  A Nicholas, Millard and Cook, 2003)
• 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)

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Summary

• Importance of client-therapist relationship in
  therapy outcome
• 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
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References

• 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)
  Parent-child 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.