1. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 5: Palin Parent-Child Interaction Frances Cook and Willie Botterill Michael Palin Centre for Stammering Children London

2. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Introduction Target population: children up to 7 years of age Principles of program: –Understand child’s needs –Encourage ways parents already use to support natural fluency –Parents develop ability to deliver therapy at home –Discuss stuttering openly

3. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Introduction (cont.) Goals of program: –Establish parental understanding, knowledge, skill, and confidence in managing stuttering –Reduce family anxiety about stuttering –Reduce stuttering to within normal limits (<3% syllables stuttered)

4. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Multifactorial Theoretical Basis Onset of stuttering has a physiologic base affecting the delicate, complex balance of linguistic and motor skill development. –Genetics –Neurophysiologic factors –Speech motor skills –Communication environment: interaction styles

5. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Palin Center Multifactorial Framework

6. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Empirical Basis Phase 1 investigations (small studies to examine potential benefit of treatment) –Matthews, Williams, & Pring (1997) single-case study of 4-year-old-male Number of words stuttered measured at 6 weeks before, during, and after therapy Reduction in stuttering during therapy and maintained at post-therapy measurement intervals

7. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Empirical Basis (cont.) Millard, Nicholas, & Cook (2008) –6 children under 5 years of age –At least 12 months post-onset –Number of words stuttered measured at 6 weeks before, during, and after therapy, and 1x/month for 1 year –Significant reductions in stuttering of 4 children by end of the Consolidation Phase (6 weeks post-treatment) –Stuttering in 5th child* decreased with one parent –Stuttering in 6th child* decreased by the end of follow-up period *Both received direct therapy during the 1-year follow-up.

8. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Empirical Basis (cont.) Phase 2 investigations (how treatment works, which clients are suitable, amount of treatment needed) –Nicholas, Millard, & Cook (2003) findings Parents make changes during Palin PCI. Changes can be maintained over time. Fathers significantly reduced requests for information and reduced their turn length. Mothers reduced number of instructions. –Millard, Edwards, & Cook (2009) findings 6 months post-treatment: reduction in expressive language scores of children with above average initial scores Interpreted to support fluency-language trade-off

9. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Empirical Basis (cont.) Phase 2 investigations (cont.) –Millard (2002) qualitative study of indicators of improvement based on parent feedback Child outcomes Reductions in stuttering frequency and severity Reductions in child’s anxiety/frustration/concern Increases in child’s confidence in speaking Increases in turn-taking skills Parent outcomes Reductions in concern Increases in confidence in managing stuttering Positive impact on the family

10. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Empirical Basis (cont.) Phase 3 investigations (large-scale efficacy research) –Combined findings of Millard, Edwards, & Cook (2009) and Millard, Nicholas, & Cook (2008) Two-thirds of children showed reduction in stuttering in Clinic and/or Consolidation periods; no direct treatment needed

11. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Empirical Basis (cont.) Phase 4 investigations (treatment effectiveness) –Early evidence that nonspecialist speech-language pathologists (SLPs) effectively implement Palin PCI –Matthews, Williams, & Pring (1997) nonspecialist clinician –Crichton-Smith (1002) replicated it with 4-year-old child.

12. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Empirical Basis (cont.) Phase 5 (study of cost effectiveness, client satisfaction, and effect on quality of life) –Reflected in the phase 2 and 3 studies

13. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Practical Requirements Three-day training workshop Assessment skills in speech, language, social communication Collaboration skills to work with families Technical equipment – video camera/monitor/tripod Sufficiently large clinic room Requisite consent forms and documentation forms

14. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Practical Requirements (cont.) Time requirements in first 3 months –Assessment/analysis = 90 minutes –Parent interview = 90 minutes –Treatment in clinic = six weekly 1-hour sessions –Consolidation phase = 6 weekly 10-minute contacts by phone, letter, or email Subsequent time requirements –Clinic visit every 3 months for 1 year

15. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Key Components Multifactorial assessment Stage 1: Within-clinic sessions Stage 2: Home-based consolidation period Stage 3: Review session and clinical decision making Monitoring only phase

16. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Key Components (cont.) Multifactorial assessment –Evaluate child’s strengths and vulnerabilities Receptive and expressive language Articulation Speech rate Social communication skills –Detail case history via parent interview Developmental, familiar, psychosocial, health, and personality factors influencing child’s stuttering Parent rating scales

17. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Key Components (cont.) Stage 1 –Initial session: Setting up Palin PCI Open dialogue about stuttering and fluency Establish expectation of joint responsibilities in PCI Review assessment findings and address questions Set up Special Time (ST) contracts (5-minute playtime each parent has with child 3-5 times per week) Parent homework sheets to be completed after ST Signing of video consent forms and taping of 5-minute interaction of child with each parent separately

18. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Key Components (cont.) –Sessions 2-6: Review ST and homework sheets, record new 5-minute video with each parent implementing their interaction targets View video of parent-child interactions to identify interaction styles supporting fluency Useful clinician questions: What is going well? What else can you see that is helping? What difference does that make? Parents identify new goal for upcoming week’s ST

19. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Key Components (cont.) Stage 2: Consolidation period –Introduced in 6th session of stage 1 –Parents continue treatment at home for 6 weeks ST and homework sheets Develop child’s confidence Promote turn taking in family Manage other relevant issues Send homework sheets to SLP weekly SLP monitors progress/responds Review session at clinic at end of 6 weeks

20. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Key Components (cont.) Stage 3: Review session –Parents complete rating scales –Discuss ST and other matters –Parents discuss changes they have made and effects –Formal fluency analysis from recorded speech samples –Parent-child interaction video made and viewed with both parents Monitoring only phase

21. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment Methods for Ongoing Decision Making Initial assessment –Analyze recorded speech sample for percent syllables stuttered (%SS); document type and duration of stutters –Interview to gauge degree of child’s concern –Video record each parent/caregiver playing with child –Detailed case history from both parents –Parent rating scales to examine knowledge, concern, and confidence in managing child’s stuttering

22. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment Methods for Ongoing Decision Making (cont.) Progress monitored throughout the initial 6-week period and the subsequent 6-week consolidation period Therapy session no longer indicated when stuttering is <3% SS in clinic and home and/or parents are no longer concerned Follow-up data collected every 6-12 weeks for up to a year after treatment

23. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Tailoring Palin PCI to the Individual Child and Family Consideration of personal/cultural factors SLP works with family to identify what works for them. Parents are not asked to use new style of interaction. Professional interpreters assist in services and advise on cultural considerations. If both parents are not available, the program proceeds with the available parent.

24. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Case Study Onset at 2 years, 5 months Monitored by SLP for 18 months; patchy fluency Stuttering increased and confidence decreased over last 6 months Assessment by Palin at 3 years, 8 months Late talker with limited vocabulary “Never spoken clearly and sounds weren’t right” Parent increasingly anxious Maternal family history of stuttering

25. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Case Study (cont.) Initial assessment –6.4% SS –Repetitions of up to 12 times –Prolongations lasted up to 6 seconds + facial tension –Delayed speech and language development –Mismatch in speech and language skills –18 months since onset –Increase in severity over time –Maternal family history of persistent stuttering –Parental anxiety –Sensitive temperament and reactivity to errors –Prognosis: Moderate to high vulnerability for persistence

26. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Case Study (cont.) Outcome after 6-week consolidation period: –Fluency had increased. –Parents were pleased with progress. –Parents were more confident in managing child’s fluency

27. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Future Directions Development of hypotheses regarding which children are likely to respond to Palin PCI Further research needed to: –Understand the mechanisms by which Palin PCI reduces stuttering –Identify the components of the program that are essential –Document effectiveness in a range of nonspecialist settings