Management of Early Childhood Stammering

Management of Early Childhood Stammering

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 [email protected] The Michael Palin Centre for Stammering Children London, England Staff 11 specialist speech & language therapists Business manager 2 administrative assistants

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 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

continued Trainee programme One to four weeks at the Michael Palin Centre Individually tailored to trainees needs Clinical supervision The Michael Palin Centre website: www.stammeringcentre.org Oxford Dysfluency Conference September 1st to 4th 2011

St Catherines College, Oxford Keynote speakers: Nan Bernstein Ratner Martin Sommer Joe Donaher Willie Botterill Ann Packman The Multifactorial Model Physiological factors Speech and language factors

Stammering Psychological factors Environmental factors 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

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 Aims 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 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 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 more of

what parents may need to be doing Interaction Strategies Evidence of Interaction Strategies Potential target 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

15 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; OHanlon and Weiner-Davis, 1989) Cognitive Behaviour Therapy (Beck, 1995) Michael Palin Centre Philosophy 1. 2. 3. The children and their parents are the experts

It is not the parents fault Children and parents are already doing helpful things 1. The children and their parents are the experts Our aim is to help them access and build on their knowledge and skills They We

already know dont need to tell them 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 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 Therapeutic style Collaborative Role as facilitator and reinforcer Who is the expert? Facilitating vs teaching or instructing Asking questions vs telling

Michael Palin Centre Style Asking not telling Finding not showing Focusing on the positive - childs and parents expertise 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 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 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 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 Palin Parent Child Interaction Therapy Palin PCI 27

Summary Chart Child's Name: Date: Stammering & Social Communication Skills % ss Parent rating Type of stammering Time since onset WWR PWR

Prol. < 6mths <12mths Better Same Pattern of change Child's awareness/concern

Talking at length/turn taking Blocking Reduced eye contact >12mths Reduced concentration Worse Parents' levels of concern Linguistic

History of delayed speech/language development Physiological Family history of stammering Reduced receptive skills

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 Evidence Interaction Strategies of

Potential target Family Strategies Helpful Mother Father Mother Child Strategies 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 28 Principles 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 29 The Palin PCI therapy programme has 3 main strands: Interaction strategies Family strategies Child strategies 30 Interaction 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 31 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 32 Child Strategies

Child Strategies Rate reduction Pausing to think Easy onset Being more concise Eye contact/focus of attention 33 Other strategies Other Language/phonology therapy School/preschool liaison Onward referral

34 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 35

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 36 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 37 Session 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 38 Further 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

39 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 40 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

41 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 42 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 Video observation of SLT Note

the questions that the therapist is asking Note any other observations about the therapists style 44 45 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 But what if.?

47 48 49 What are the benefits of using this style with parents? What 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 What 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

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 Palin Parent Child Interaction Therapy: the manual 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 Percentage Design 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 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 (RDLS3) to within normal limits (Study B) 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) 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 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

61-76. Millard, S.K., Nicholas, A. & Cook, F.M. (2008). Is ParentChild Interaction Therapy Effective in Reducing Stuttering? Journal of Speech, Language and Hearing Research, 51(3), pp 636-650.

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