1. 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:

2. The Michael Palin Centre for Stammering Children
London, England

3. Staff 11 specialist speech & language therapists Business manager
2 administrative assistants

4. 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
Describe training
Invite trainees
Describe research
Management of Early Childhood Stammering 4

5. 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

6. continued Trainee programme
One to four weeks at the Michael Palin Centre
Individually tailored to trainee’s needs
Clinical supervision

7. The Michael Palin Centre website: www.stammeringcentre.org

8. 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

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

10. 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

11. 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

12. 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

13. Factors associated with recovery and persistence
Michael Palin Centre for Stammering Children
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
This list mainly from risk factor research but parental/child concern overules therapy decision
STOP PRESS – latest research about sudden severe onset & recovery ?Mansson at ODC 2008 – this needs to be checked
Management of Early Childhood Stammering 13

14. 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

15. Interaction Strategies
Helpful
Evidence of
Potential target
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

16. Michael Palin Centre for Stammering Children
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)
A number of different psychological and counselling approaches have contributed to the evolution of Palin PCI to its current form and our style of working.
These are
Solution Focused Brief Therapy (DeShazer , 1988; 1996; O’Hanlon and Weiner-Davis, 1989 ),
Cognitive BehaviourTherapy (Beck,1995),
Family Systems theory (Epstein & Bishop 1981)
Personal Construct Psychology (Fransella, 1972; Kelly, 1955) and
Greater emphasis is now placed on developing the parent-therapist relationship and using a collaborative style
The therapist’s role is one of facilitator and reinforcer, providing feedback that focuses on strengths.
Management of Early Childhood Stammering

17. Michael Palin Centre Philosophy
Michael Palin Centre for Stammering Children
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
Why do we use this style?
Palin PCI is based on 3 main premises
We believe that parents have an intuitive understanding of what their child needs to be more fluent.
We also know from research that parents of CWS are no different to parents of CWNS in terms of their interaction style.
We believe that parents are already doing helpful things, which we want to encourage them to do more of.
Management of Early Childhood Stammering

18. 1. The children and their parents are the experts
Michael Palin Centre for Stammering Children
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
The first premise – that parents have intuitive understanding
What do most parents want to say to their child who stammers?
What does this tell us that they have instinctively realised?
If you ask parents when their child’s stammering is worse, what do they typically say? Better?
Parents bring to therapy a wealth of instinctive knowledge, but often they do not know that they know
They don’t need us to tell them
They need us to help them access this knowledge and their skills
Link to what they identified from Jayneequa and comment on you will see more of how we achieve this in subsequent videos.
How can we do this?
Extra notes below:
We asking them, we don’t tell them
We elicit information, using core counselling skills, specifically: asking questions, active listening, accepting, reflecting and summarising. We are all accustomed to asking questions during an assessment. Palin PCI continues with the ‘asking’, we don’t switch to ‘telling’ when therapy starts.
We build knowledge by eliciting, not teaching
We could build parents’ knowledge by working through a list of facts which we wish to impart. They may acquire the same knowledge and skills, but the process may not have equipped and empowered them.
Eliciting their insights and instinctive understanding shows them that they already have valuable knowledge.
Example
We could tell parents the things that seem to affect a child’s fluency, like time pressure, his emotional state or linguistic complexity. Or
We could ask parents “What seems to help your child to be more fluent?”
“When is his speech better?”
“When does he stammer more?”
“What do you think he needs to do to stammer less?”
“What do you do or say to help him when he is stammering?”
“How do you think that is helping him?”
In our experience, parents can often answer these questions, because they know their child and what affects him. Drawing this knowledge from them is empowering and memorable. Telling them may be deskilling and forgettable.
We develop skills by finding notshowing
Similarly, if we want to develop a parent’s skills we could demonstrate that skill, model it for the parent and train them in how it should be done. The parent might appreciate being shown exactly what is required, but they might also feel rather inadequate, thinking they could never do it like the expert.. Alternatively we could find examples, however small, of when they are already using that skill and show them that they can do it, they have been doing it before.
We could show a parent how to match their linguistic complexity to the child’s level by playing with the child and talking to him at the appropriate level
We could look at a recording of the parent playing and talking with the child and find an example of when they are using the appropriate level and then show that example to the parent.
Or, better still,
We could look at a recording with the parent and ask them to find an example of when they are using the appropriate level.
A therapist modelling how to do something might make parents feel they could never do it as well as they should. Identifying examples of when parents are already using their skills to help their child’s fluency increases their confidence in their own ability.
Management of Early Childhood Stammering

19. 2. It is not the parents’ fault
Michael Palin Centre for Stammering Children
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
The second premise: Parents of CWS are not regarded as being different from parents of CWNS in terms of their interaction style.
This principle is supported by research findings:
Parents of CWS are no different from parents of CWNS in terms of their:
rate of speech (eg Kelly, 1994)
response time latencies (eg Zebrowski, 1995)
interrupting behaviours (eg Meyers and Freeman, 1985)
levels of assertiveness and responsiveness (eg Weiss and Zebrowski, 1991)
Parents of CWS are not interacting in different ways with their child but due to the child’s underlying vulnerability to stammering they are finding it hard to cope with the typical style that parents use with children
We also know that parents can change their interaction styles & when they do, the child’s fluency improves
So parents are no different and they have not done something to cause their child’s stammering
But parents often tell us that they feel guilty. And when we work with them on their interaction we may be unwittingly making them feel that they have been doing something wrong.
We tell them that the research says they are not doing anything different, but that their child may need a modified style of interaction in order to help him to be more fluent. The underlying difficulties which predispose the child to stammer also make it more difficult for him to be fluent in the context of typical adult-child interactions
We hope that this will help to reduce parental guilt and help them to understand that
Management of Early Childhood Stammering

20. 3. Children and parents are already doing helpful things
Michael Palin Centre for Stammering Children
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
The third premise is Parents are already doing helpful things.
We do not focus on what is wrong, we are not focusing on what they need to stop doing but rather focusing on what they are already doing that is helpful and what they can do more of.
By focusing on these strengths, PCI is aiming to:
Develop parents’ confidence in their own knowledge and skills
Develop parents’ skills in order to equip and empower them
Develop parental independence of the SLT and self-reliance
So the three main premises of Palin PCI underpin both our theoretical stance as well as the style in which we work.
Management of Early Childhood Stammering

21. Therapeutic style Collaborative Role as facilitator and reinforcer
Who is the expert?
Facilitating vs teaching or instructing
Asking questions vs telling

22. Michael Palin Centre Style
Michael Palin Centre for Stammering Children
Michael Palin Centre Style
Asking not telling
Finding not showing
Focusing on the positive
- child’s and parents’ expertise
So you’ve identified a no. of different skills that E was using during that clip. Here is a summary of what we see as beign the key components of the Palin PCI style
We are asking lots of questions rather than giving info or telling them what to do - eliciting from them what they already know about what helps their child’s fluency
We aim to find rather than show – rather what they should/shouldn’t be doing to help their child’s fluency, identifying what they are already doing to help their child
So we are focusing on the positive – focusing on their expertise and helping them to do more of what helps
Management of Early Childhood Stammering

23. 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

24. Video is used throughout assessment and therapy
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

25. MPC therapy approaches
Michael Palin Centre for Stammering Children
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
Management of Early Childhood Stammering

26. Michael Palin Centre for Stammering Children
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, 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
Management of Early Childhood Stammering

27. Palin Parent Child Interaction Therapy
Palin PCI

28. 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 Strategies
Mother
Father
Following child's lead in play
Special Times
Rate reduction
Letting child solve problems
Pausing to think
More comments than questions
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
Language/phonology therapy
Time to initiate, respond, finish
Sleep
School/preschool liaison
Rate of input when compared to child's rate
Onward referral
Use of pausing
Using eye contact, position, touch, humour &/or surprise
Praise and encouragement
Emerging issues

29. 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

30. The Palin PCI therapy programme has 3 main strands:
Interaction strategies
Family strategies
Child strategies

31. 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

32. 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

33. Child Strategies Child Strategies Rate reduction Pausing to think
Easy onset
Being more concise
Eye contact/focus of attention

34. Other strategies Other Language/phonology therapy
School/preschool liaison
Onward referral

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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
Video observation – AN with Olivia
EK with Evan (mock up rather than real session) 43

44. Video observation of SLT
Note the questions that the therapist is asking
Note any other observations about the therapist’s style
We are now going to look in more detail at aspect of the style which is used in Plain PCI, watching videos of therapy sessions.
This video is another actual therapy session. The child is making a lot of noise in the room, making it difficult to hear what the father says at times. We want you to focus on what the therapist is saying (which is loud and clear)& write down her questions & any other observations
Evan – Clip 1 = 4 mins
2 = 2:30 mins
3 = 6 mins
Comment here – routine questions we all ask as part of our assessment but quite often responses remain on the case history form. In Palin PCI we return to the questions and the answers during therapy and make active use of parents’ responses 44 44

45. 45

46. 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?
Now we want you to have a go at using Palin PCI - we want you to practise being either the therapist or the parent, using the questions you have heard, as well as others we will suggest.
Role of parent
When he is relaxed, in one to one setting, taking his time, giving simple answers, concentrating on what he is saying
When he is excited, tired, in a hurry, saying something complicated, unwell, competing to speak, thinking about two things at once
Take his time, think before he speaks, breathe, relax (Tell him to calm down, take his time, don’t let other children interrupt him, get down to his level)
Allowing silences, taking my time, giving him lots of time to answer a questions, letting him be in charge, just talking about what is happening now
He will give himself time to think, plan & articulate what he wants to say: time to think of words, construct sentence, puts in right sounds; he will use language which is not too complicated; he will be able to focus on what he is trying to say; he won’t worry that I am going to interrupt him
Follow his lead, allow longer pauses, make more comments & ask fewer questions 46 46

47. But what if…………….?
In pairs think of potential difficulties with using this style in working with parents
What might tempt us to play it safe and just tell the parents or show them by modelling 47 47

48. 48

49. 49

50. What are the benefits of using this style with parents?

51. What parents have said (Mother of Holly, aged five)
“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 51

52. What parents have said (Mother of Kai, aged seven)
“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)
We have been very impressed with the way you have tailored what you offer to what we have needed. We feel very lucky that we have access to you.’ (Father of Lucy, aged three) 52 52

53. 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” 53 53

54. Palin Parent Child Interaction Therapy: the manual

55. 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

56. 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 (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

57. 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)

58. 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)

59. Eliciting not teaching
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 59

60. Michael Palin Centre for Stammering Children
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
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  
Management of Early Childhood Stammering 60