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