the michael palin centre: palin parent child interaction therapy elaine kelman the michael palin...
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The Michael Palin Centre:The Michael Palin Centre:Palin Parent Child Interaction TherapyPalin Parent Child Interaction Therapy
Elaine KelmanElaine Kelman
The Michael Palin Centre for Stammering ChildrenThe Michael Palin Centre for Stammering ChildrenFinsbury Health Centre, Pine St, London EC1R OLPFinsbury Health Centre, Pine St, London EC1R OLP
Telephone: 0207 530 4238Telephone: 0207 530 4238
The Michael Palin Centre for The Michael Palin Centre for Stammering ChildrenStammering Children
London, EnglandLondon, England
StaffStaff
11 specialist speech & language therapists
Business manager
2 administrative assistants
The Michael Palin Centre for The Michael Palin Centre for Stammering ChildrenStammering 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
Training programmeTraining programme
2 or 3 day training courses inPalin Parent-Child Interaction Therapy
(under 7s)Family interaction (7 – 14s)Working with teenagersDirect fluency skillsCognitive Behaviour TherapySolution Focused Brief Therapy
continuedcontinued
Trainee programme
One to four weeks at the Michael Palin Centre
Individually tailored to trainee’s needsClinical supervision
The Michael Palin Centre website:The Michael Palin Centre website:www.stammeringcentre.org
Oxford Dysfluency Oxford Dysfluency ConferenceConference
September 1st to 4th 2011
St Catherine’s College, OxfordKeynote speakers:
Nan Bernstein Ratner
Martin Sommer
Joe Donaher
Willie Botterill
Ann Packman
Speech and language factors
Environmental factors
Physiologicalfactors
Psychologicalfactors
Stammering
The Multifactorial ModelThe Multifactorial Model
A Multifactorial FrameworkA 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 Importance of comprehensive assessmentassessment
Assessment should includeSpeech and language skills (at all ages)Fluency assessment, including thoughts
& feelings about stammer & its impact on the child & family
Aims of assessmentAims 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 pathwayTo identify components of individually
tailored treatment programme
Factors associated with Factors associated with recovery and persistencerecovery 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 Assessment of parent child interactioninteraction
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 StrategiesInteraction Strategies
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Interaction Strategies Helpful
Evidence of
Potential target
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
Psychological/counselling Psychological/counselling approaches which have influenced approaches which have influenced
the Michael Palin Centrethe Michael Palin CentreBehaviour therapyFamily 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 PhilosophyMichael Palin Centre Philosophy
1. The children and their parents are the experts
2. It is not the parents’ fault
3. Children and parents are already doing helpful things
1. The children and their 1. The children and their parents are the expertsparents 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’ fault2. 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 3. Children and parents are already doing helpful thingsalready doing helpful things
So we need to develop:their confidence in their own knowledge
and skillstheir skills in order to equip and
empower themtheir independence of the therapist to
increase their self-reliance
Therapeutic styleTherapeutic style
CollaborativeRole as facilitator and reinforcerWho is the expert?Facilitating vs teaching or instructingAsking questions vs telling
Michael Palin Centre Style Michael Palin Centre Style
Asking not telling Finding not
showing Focusing on the
positive
- child’s and parents’ expertise
Involvement of the family systemInvolvement of the family system
Difficulties of transferring fluency from the clinic to the real world
Child changes family changesParents can be the vehicle of change
Use of videoUse of videoVideo is used throughout assessment and
therapyOutcome measurementHelps child & parents to be objective
about selves – develops autonomyDesensitisationProvides feedback about strengths and
progress
MPC therapy approachesMPC therapy approachesPalin Parent Child Interaction TherapyLidcombe ProgrammeOther direct fluency programmes for young
childrenFamily Interaction Therapy Integrated fluency shaping and speech
modification therapyCognitive Behaviour TherapySolution Focused Brief TherapyPersonal Construct Psychology
DeliveryDelivery
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
27Palin PCIPalin PCI
Palin Parent Child Palin Parent Child Interaction TherapyInteraction Therapy
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Summary Chart Child's Name: ……………………………………………………… Date: …………………………………
Stammering & Social Communication Skills
% ss Parent rating Child's awareness/concern
Type of stammering WWR PWR Prol. Blocking Talking at length/turn taking
Time since onset < 6mths <12mths >12mths Reduced eye contact
Pattern of change Better Same Worse Reduced concentration
Parents' levels of concern Linguistic
History of delayed speech/language development
Physiological Reduced receptive skills
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
Interaction Strategies Helpful
Evidence of Potential target
Family Strategies Child StrategiesMother Father Mother 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
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Principles underlying Palin PCI Principles underlying Palin PCI 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
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The Palin PCI therapy programme has 3 main strands:
Interaction strategiesFamily strategiesChild strategies
Interaction StrategiesInteraction Strategies
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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
Family StrategiesFamily Strategies
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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
Child StrategiesChild Strategies
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Child Strategies
Rate reduction
Pausing to think
Easy onset
Being more concise
Eye contact/focus of attention
Other strategiesOther strategies
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Other
Language/phonology therapy
School/preschool liaison
Onward referral
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Interaction researchInteraction 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 PCIOverview of Palin PCI
Six weeks PCI Once per weekWith both parents/carers and childOne hour sessionsSix weeks Consolidation PeriodReview session
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Session 1Session 1
Set up Special Times5 minutes onlyChild chooses activityWhat to avoid: books, boisterous play,
TV, computerAfter Special Time is completed, return
to the activity if desiredOffer Special Times to siblings
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Session TwoSession TwoReview of Special TimesDiscuss the child’s abilities and vulnerabilities and what might helpWatch PCI videoAsk parent to notice what they are already doing to help their child’s
fluencyDiscuss how a particular strategy might be helping their child’s
fluency Agree a strategy that they will try to do more ofGive family strategy handout
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Further sessionsFurther sessions
Review of Special TimesWatch PCI videoVideo feedback:
– what they are doing that is helping the child’s fluency – positive effects
Identify new target & rationaleDiscuss family strategyGive family strategy handout
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Consolidation PeriodConsolidation 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 appointmentReview 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 modificationSpeech modification
Strategies:Tortoise talking – rate reduction (based on
Meyers & Woodford, 1992) Bus talking – pausing to thinkAeroplane talking – use of gradual
onset to speech
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Format of sessionsFormat 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 SLTVideo 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 askRole 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…………….?But what if…………….?
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What are the benefits of using What are the benefits of using this style with parents?this style with parents?
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What parents have saidWhat 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 saidWhat 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 saidWhat 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”
Palin Parent Child Interaction Palin Parent Child Interaction Therapy: the manualTherapy: the manual
Children at high risk of persistent stammering (stammering >12 months)
Age 2 – 5 years at start of studyNo therapy in previous 6 monthsEnglish as main language at homeNo identified learning difficulties,
disorders or syndromes
Effectiveness of Palin PCI:Effectiveness of Palin PCI: 2 multiple single subject studies 2 multiple single subject studies
DesignDesign 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)
Study B (N=6) – recordings made once a week for six weeks prior to 6 month review
ResultsResults 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)
Results continued………..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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SummarySummary
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 tellingAsking not tellingEliciting not teaching Eliciting not teaching Finding not showingFinding not showing
ReferencesReferences
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.