Palin Parent-Child Interaction Therapy for Early Childhood Stammering

Elaine Kelman, Alison Nicholas

• Publisher: Routledge
• Year: 2020
• ISBN:
  9781351122337
• Edition: 2
• Topic: Pedagogía
• Subtopic: Educación general

Now available in a fully revised and updated second edition, this practical manual is a detailed guide to the Palin Parent–Child Interaction Therapy programme (Palin PCI) developed at the Michael Palin Centre for Stammering (MPC). Palin PCI builds on the principle that parents play a critical role in effective therapy and that understanding and managing stammering is a collaborative journey between the child, parent and therapist. This book emphasises a need for open communication about stammering, offering a combination of indirect techniques such as video feedback, interaction strategies and confidence building, along with direct techniques to teach a child what they can do to help themselves.

This second edition:

• Reflects the most up-to-date research in areas such as neurology, genetics, temperament and the impact of stammering on children and their families
• Offers photocopiable resources, such as assessment tools, information sheets and therapy handouts, to support the implementation of Palin PCI
• Focuses on empowerment through building communication confidence in children who stammer and developing knowledge and confidence in their parents

Based on a strong theoretical framework, this book offers a comprehensive understanding of the Palin PCI approach in order to support generalist and specialist speech and language therapists as they develop their knowledge, skills and confidence in working with young children who stammer and their families.

For more information about Alison and her work, please visit www.alisonnicholasslt.co.uk. To learn more about Elaine and her work, please visit www.michaelpalincentreforstammering.org.

1
Introduction and theoretical background

This second edition represents an update of Palin Parent–Child Interaction Therapy, a therapy intervention for young children up to the age of seven years who stammer, developed at the Michael Palin Centre for Stammering for use by generalist therapists. In the time since the publication of the first edition there has been a plethora of research to underpin and enhance our understanding of early childhood stammering, which has informed and developed our assessment and therapy methods.

In this first chapter we present a comprehensive overview of the research to date which informs our understanding of the factors that underlie and influence stammering, culminating in the Palin Model, a multifactorial representation of the research findings, providing a clinical tool for assessment and therapy. This is followed in Chapter 2 with a summary of the research which we need to consider when deciding which children who start to stammer need intervention.Chapter 3 presents an overview of Palin Parent–Child Interaction (Palin PCI), how it was developed and the influences that have shaped it over the years, as well as the principles that underlie this approach and the evidence base for the effectiveness of Palin PCI.

We describe the application of this theoretical understanding, starting in Chapter 4 with the screening tool, as well as the process of giving advice and monitoring for those children who do not require assessment and therapy.

The assessment process is described in Chapter 5, involving the child assessment and case history to identify the child’s strengths and vulnerabilities in the context of his family. This enables us to present the formulation, described in Chapter 6, to the parents, so that they will understand which factors underlie and influence the child’s stammering as well as the components of the therapy programme which are individually tailored to the child and family.

The therapy is presented in the next four chapters. Interaction, Family and Child Strategies are described in Chapters 7,8 and 9, followed by a description of how Palin PCI can be adapted in Chapter 10.

We illustrate the Palin PCI approach with case studies based on the children and families we have worked with. We have also included observations made by parents and therapists, in order to provide some real-life user feedback. The Appendix consists of the resources for therapists to copy and use in their own clinical practice: assessment forms, handouts and other documents.

It is our intention that therapists will be able to implement Palin PCI by developing their knowledge, skills and confidence from this manual. We also run practical training courses in Palin PCI where the discussions, practical exercises and video demonstrations facilitate therapists’ skills developmentin an active learning environment. Our research into our training programme has demonstrated that therapists’ knowledge, skills and confidence are not only built up during the training course, but they are maintained after the course and the therapists report that the skills learned are highly transferable to other client groups (Botterill, Biggart & Cook, 2006). For those who wish to continue this process, ongoing supervision is available leading to Accredited Palin PCI Therapist status. For more information about training courses and accreditation see www.michaelpalincentreforstammering.org.

In line with the usual conventions, we will use the pronouns ‘he’ when referring to the child and ‘she’ when referring to the therapist. When we use the term ‘parents’ we are also referring to any other primary caregiver, e.g. foster parent, grandparent.

Over the years we have used Palin PCI with many hundreds of children, each with their own individualised programme and we continue to be excited and intrigued by this therapy as it empowers parents and equips children who stammer to become confident and competent communicators. We hope you find this book informative and that you will feel equipped and inspired as we are to work with this fascinating group of children and their parents.

What is stammering?

Stammering occurs in all parts of the world, across all cultures, religions and socio-economic groups. It is a complex problem that may be referred to as stammering or stuttering.

There is no uniform definition of stammering and terminology varies in clinical practice. The following speech disfluencies are most often produced by young children who stammer (Guitar, 2014; Yairi & Seery, 2015; Yaruss & Reardon-Reeves, 2017):

• Repetition of single syllable whole words, for example ‘I-I-I-I like chocolate’; ‘and-and-and I like chocolate’.
• Repetition of sounds or syllables, for example ‘I like ch-ch-ch-chocolate’; ‘I like cho-cho-cho-chocolate’.
• Prolongation of sounds, for example ‘I lllllllllike chocolate’.
• Blocking of sounds, where the articulators are in position, but no sound comes out, for example ‘I liked ch…ocolate’.

These types of disfluency, most typically seen in stammering, are referred to as the core features of stammering. Much less common are word final disfluencies: word final repetitions, e.g. I went-ent-ent to the park-ark; mid word insertion/breaks – such as the insertion of ‘h’, e.g. I we-hent to the pa-hark; final sound prolongations, e.g. I like going on the bussssss; final phrase repetitions, e.g. I went to the park-the park-the park. These are referred to as atypical disfluencies (see Sisskin & Wasilus, 2014).

Stammering may be accompanied by:

• Physical tension, for example in the muscles around the eyes, nose, lips or neck.
• Struggle behaviour, for example concomitant body movements which occur as the child attempts to ‘push’ the word out, e.g. stamping the feet, disrupted breathing. These features are often referred to as secondary behaviours.

In addition, the child may adopt strategies to try and minimise or hide the problem, for example:

• Avoiding or changing words – the child may say ‘I’ve forgotten what I was going to say’, or may switch to another word when he begins to stammer, for example ‘played with my br- br- br… my sister on Saturday’.
• Avoiding certain situations – for instance, not contributing during circle time at nursery or not putting his hand up to answer a question at school.

These are called avoidance or safety behaviours. As they get older, some children become so adept at hiding their problem in this manner that they may appear not to stammer, or just become very quiet.

We also know that even in the preschool years the speech disfluencies of children who stammer can be accompanied by negative emotional reactions such as frustration, embarrassment and anxiety. Stammering is therefore complex and involves more than the core speech disfluencies described above (see Guitar, 2014; Reardon-Reeves & Yaruss, 2013; Yairi & Seery, 2015).

‘Stuttering is more than just stuttering’ (Reardon-Reeves & Yaruss, 2013, p. 8)

A young child’s speech may also feature other types of speech disfluencies, such as:

• Hesitations or pauses, for example ‘I like … cats’.
• Interjections, for example ‘I like uh cats’.
• Revisions, for example ‘I like – really love cats’.
• Multisyllabic whole word repetitions, for example ‘because-because-because I like cats’.
• Phrase repetitions, for example ‘I like-I like cats’.

Whilst these speech disfluencies may occur in the speech of children who stammer alongside their core stammering behaviours, they are also commonly found in the speech of preschool children who do not stammer. They are referred to as normal disfluencies, typical disfluencies, other disfluencies or non-stammered disfluencies. In the past, a speech and language therapy assessment for a young child referred because of concern about stammering was focused on identifying whether a child was stammering or experiencing the typical or normal disfluencies (normal non-fluency) found in the speech of young children who do not stammer. However, we now know, for the most part, that the disfluencies of a young child at the onset of stammering are noticeably different in both quantity and quality from the disfluencies of a typically fluent child (Yairi & Ambrose, 1999). We also know that parental report of stammering is usually highly accurate (Einarsdottir & Ingham 2009; Onslow & O’Brian, 2013; Yairi & Ambrose, 2005). As suggested by Yairi & Ambrose (2005), diagnosing stammering in young children is therefore straightforward.

The onset of stammering

Most stammering begins in early childhood, usually appearing between the age of two and four years, coinciding with a period of rapid development of speech, language and motor skills (see Yairi & Ambrose, 2013). Whilst the onset of stammering has typically been regarded as gradual, more recent data suggests that onset of stammering is as likely to be described by parents as sudden (i.e. over two to three days) (Yairi & Ambrose, 2005; Reilly et al., 2009).

Around the time when it first emerges, the ratio of boys to girls affected by stammering is nearly equal (Kloth, Kraaimaat, Janssen & Brutten, 1999; Mansson, 2000; Yairi & Ambrose, 2005). However, this ratio gradually increases with age and in school-aged children and adults who stammer the ratio is reported to be as high as 5:1 or 6:1 boys to girls (Bloodstein & Bernstein Ratner, 2008), indicating that more girls than boys stop stammering.

The generally accepted figures for the prevalence of stammering (i.e. how many people currently stammer) and the incidence rate (i.e. how many people have stammered at some time in their lives) is approximately 1 per cent and 5 per cent respectively (Bloodstein & Bernstein Ratner, 2008). However, more recent studies have suggested that the incidence rate could be 8 per cent or even higher (Reilly et al., 2013b; Yairi & Ambrose, 2013).

Individuality and variability

One common feature of early stammering is its variability (Yaruss, 1997). A child’s stammer can vary from day to day and situation to situation and is influenced by a number of different factors, including the child’s language (Wagovich & Hall, 2018), the context in which he is speaking (Yaruss, 1997), the interaction style of the person he is talking to (Guitar & Marchinkoski, 2001), as well as how the child is feeling at the time (Vanryckeghem, Hylebos, Brutten & Peleman, 2001). Phases of stammering are often interspersed with fluent periods, which may last for weeks, and it can be difficult to identify any reasons for these fluctuations.

Why do some children stammer?

There is general consensus among experts that stammering is a complex, neurodevelopmental disorder that develops from an interaction of several factors (Smith & Kelly, 1997; Smith & Weber, 2017; Starkweather, 2002). In light of research findings over the past decade, we have modified our multifactorial model, with genetic and neurological factors underlying the cause of stammering, whilst language and communication, psychological, speech motor and environmental factors influence its onset, development, severity and impact over time. This research base into the causes of stammering is ever increasing, particularly in the fields of neurology, genetics and temperament, and this chapter summarises what we have learned to date, which will need to be augmented by future findings as they emerge and develop our understanding.

Here we present an overview of the evidence which informs the Palin Model, our summary and understanding of why children stammer and what therefore we need to consider in our assessment and therapy. This understanding enables us as therapists to explain to parents what is influencing their child’s stammer and what our therapy needs to include.

Physiological factors

Genetics

Evidence accumulated over the past several decades has indicated that genetic factors are involved in stammering (see Kraft & Yairi, 2011; Yairi & Ambrose, 2013).

Family history of stammering

Early research into the role of genetics in stammering was based on family incidence data where the percentage of people who stammer having relatives with histories of stammering was calculated. The percentage has varied from between 30 to 60 per cent of people who stammer reporting at least one family member who stammers (Bloodstein & Bernstein Ratner, 2008). Although this research showed that stammering tended to cluster in families, further research was needed to conclude that stammering had an underlying genetic cause.

If stammering were a purely genetic condition, monozygotic twins (i.e. identical twins) would show perfect concordance in terms of stammering: both twins would stammer. Although twin studies have shown that identical twins consistently display a higher concordance for stammering than fraternal twins, concordance is not 100 per cent (Howie, 1981; Felsenfeld et al., 2000). This research has demonstrated that genetic factors by themselves do not explain all stammering and other environmental factors are necessary for stammering to develop (Felsenfeld et al., 2000; Rautakoski, Hannus, Simberg, Sandnabba & Santtila, 2012). Starkweather (2002) referred to stammering as a complex genetic trait, an epigenetic disorder, with stammering having the propensity to interact with a range of internal and external variables.

Which genes are involved?

Studies to date have shown there does not seem to be a single ‘stammering gene’. Rather, genes associated with stammering have been found on a number of chromosomes (e.g. Frigerio-Domingues & Drayna, 2017; Riaz et al., 2005; Suresh et al., 2006). Further research is needed to understand these findings more clearly and in particular the role of these genes in the onset of stammering. We are therefore still a long way from understanding what is being transmitted; however, it is likely that genetics contributes to differences in brain structure and function found to be associated with stammering (Chang, Erickson, Ambrose, Hasegawa-Johnson & Ludlow, 2008).

Brain structure and function

Neuroimaging research has shown that stammering is associated with differences in the brain; for reviews see Chang (2014) andChang, Garnett, Etchell & Chow (2018). Subtle differences have beenfound in both the brain anatomy (structure) and brain physiology (function) of those who stammer compared with their fluent peers. Whilst findings are not entirely consistent across the various studies, in general individuals who stammer have shown atypical structural and functional characteristics in the left hemisphere areas and excessive activity in the right hemisphere. These differences have been found in the brain regions that are interconnected and work together to make fluent speech planning and production possible.

Due to the practical ...