The Michael Palin Centre for Stammering Children London, England

1. The Michael Palin Centre:Palin Parent Child Interaction TherapyElaine KelmanThe Michael Palin Centre for Stammering ChildrenFinsbury Health Centre, Pine St, London EC1R OLPTelephone: 0207 530 4238elaine.kelman@islingtonpct.nhs.uk

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

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 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

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

16. 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)

17. 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

18. 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

19. 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

20. 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

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 • Asking not telling • Finding not showing • Focusing on the positive - child’s and parents’ expertise

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. 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 • 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

26. 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, 15+years) with 1 year follow up • Weekly term-time groups • All based on initial and on-going assessment of need and suitability

27. Palin Parent Child Interaction Therapy Palin PCI

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

32. Family Strategies

33. Child Strategies

34. Other strategies

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 43

44. Video observation of SLT Note the questions that the therapist is asking Note any other observations about the therapist’s style 44

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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? 46

47. But what if…………….? 47

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