Title: 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 elaine.kelman@islingtonpct.nhs.uk
1The 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
2The Michael Palin Centre for Stammering
Children London, England
3Staff
- 11 specialist speech language therapists
- Business manager
- 2 administrative assistants
4The 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
5Training 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
6continued
- Trainee programme
- One to four weeks at the Michael Palin Centre
- Individually tailored to trainees needs
- Clinical supervision
7The Michael Palin Centre websitewww.stammeringce
ntre.org
8Oxford Dysfluency Conference
- September 1st to 4th 2011
- St Catherines College, Oxford
- Keynote speakers
- Nan Bernstein Ratner
- Martin Sommer
- Joe Donaher
- Willie Botterill
- Ann Packman
9The Multifactorial Model
Speech and language factors
Physiological factors
Environmental factors
Psychological factors
Stammering
10A 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
11Importance 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
12Aims 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
13Factors 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
14Assessment 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
15Interaction 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
16Psychological/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)
17Michael 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
181. 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
192. 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
203. 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
21Therapeutic style
- Collaborative
- Role as facilitator and reinforcer
- Who is the expert?
- Facilitating vs teaching or instructing
- Asking questions vs telling
22Michael Palin Centre Style
- Asking not telling
- Finding not showing
- Focusing on the positive
- - childs and parents expertise
23Involvement 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
24Use 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
25MPC 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
26Delivery
- 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
27Palin Parent Child Interaction Therapy
Palin PCI
28 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?
1
2
3
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
29Principles 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
30- The Palin PCI therapy programme has 3 main
strands - Interaction strategies
- Family strategies
- Child strategies
31Interaction 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
32Family 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
33Child Strategies
Child Strategies
Rate reduction
Pausing to think
Easy onset
Being more concise
Eye contact/focus of attention
34Other strategies
Other
Language/phonology therapy
School/preschool liaison
Onward referral
35Interaction 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
36Overview of Palin PCI
- Six weeks PCI
- Once per week
- With both parents/carers and child
- One hour sessions
- Six weeks Consolidation Period
- Review session
37Session 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
38Session 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
-
39Further 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
-
40Consolidation 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
41Review 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
42Speech modification
- Strategies
- Tortoise talking rate reduction (based on
Meyers Woodford, 1992) - Bus talking pausing to think
- Aeroplane talking use of gradual onset to
speech
43Format 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
43
44Video observation of SLT
- Note the questions that the therapist is asking
- Note any other observations about the therapists
style
44
4545
46Role 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?
46
47But what if.?
47
4848
4949
50What are the benefits of using this style with
parents?
51What 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
52What 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
53What 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
53
54Palin Parent Child Interaction Therapy the manual
55Effectiveness 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
56Design
- 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
57Results
- 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)
58Results 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)
59Summary
- 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
59
60References
- 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.