Case Presentation:Ciaran, 4:6, preschool

stammeringBy: Rachel Kennedy

11007281Clinical Placement 3

Summary of Presentation

Background to case: Client: Ciaran Gender: Male Age: 4:6Reason for Referral to Child Health Services:

Ciaran’s parents were concerned about his stammering & sought referral from GP.

Consent: obtained from Practice Educator & Ciaran’s mum for student SLT to work with Ciaran and collect information for academic & therapeutic cause.

History Pregnancy & Birth: Born by C-Section

@ 36 Weeks; Mum suffered from Symphisis Pubis Dysfunction (SPD). Birth weight 8 lbs 10 oz (WNL).

Family: older brother who presented with a speech delay. This quickly resolved.

Medical: In good health, no other issues reported

Developmental: Reached all developmental milestones

Record of SLT Attendance: Chronological Referred by GP due to mum’s

concerns @ 3:11 after 10 months of stammering.

Seen for first part of IA @ 4:1 - Mum & school received home programme and management advice. Waitlisted for therapy.

Started therapy block with CELF-P2, PCI child & parent questionnaire @ 4:5. PCI Assessment of Stammer completed 2 weeks into therapy block.

History of StammeringLength of time with dysfluency: approximately 17-

18 months, or since he turned 3 (at risk of chronic stuttering; however, not yet past length of time at which it is reported young male stutterers may recover; Walton & Wallace 1998, Stewart & Turnbull, 2007).

Type of onset: Gradual, worsening over timeAwareness of stammer: no awareness reported,

nor observed during sessions.

Current Client Profile (McCormack & Worrall, 1998)

Body Structures & Functions

4:6 Stuttering Age appropriate in all other areas of

development from informal observation: motor skills, gross & fine; problem solving; cognition. NAD/R re: hearing, vision.

Language within normal limits & above average (Assessment with CELF-P2): Standard score 110; Sentence structure 9, word structure 10, expressive vocabulary 16

Current Client Profile: ICFActivities & Participation

Environmental FactorsLives at home with mum,

dad and 8 y/o brotherMum very motivated to

work with Ciaran at home to directly and indirectly target his dysfluency. Concerned about his stuttering: 5/7 on a rating scale.

Preschool staff have been eager to learn more about how to help Ciaran.

Personal Factors

Team work for Ciaran:The people in Ciaran’s life who can contribute to making a difference for Ciaran and his stuttering

Assessment

Assessment (Continued)

Assessment Results Significant level of parental concern (Mum rates

severity of stutter as 5/7).Age appropriate speech and language & higher:

CELF-P2 Standard Score of 110; SS 9, WS 10 & EV of 16 (!)

Age appropriate pragmatics & social communication.Severe Stutter, 26.7% (>14%, Guitar, 2013). NB:

snapshot!Manitoba Prioritization Scale: P1 for therapy.

Stuttering Severity & Types: Multiple repetitions (whole

and part word) and prolongations

Queried possible presence of silent blocks:

Increased facial and laryngeal tension noted when Ciaran is excited and/or impatient during therapy.

DiagnosisSevere (Guitar 2013, Ward 2008)Borderline Stammering (Guitar, 2013)No evidence of frustration with stammering, and

no evidence of self awareness either reported in clinic or from mum.

Tentative however – early signs of secondary behaviours?

7 Steps Case Management (Dodd, 1995)

Is Intervention Indicated?

Risk Factors for Persistent StammerMalePositive Family History of S&L issuesEvidence of disparity in language profile abilities: some

aspects WNL for age, others above expectations.Evidence of dysfluency behaviours thought to be much

more prevalent in children who stutter versus children with normal dysfluency: dysrhythmia, prolongations (Stewart & Turnbull, 2007)

No evidence of pattern to stutter, or trigger; fluctuates without apparent cause (as reported by mum).

Episode of Care

Clinical Observations

Clinical ObservationsIncreasing the length of utterances, or increasing

the cognitive effort required to produce desired language both increased severity of Ciaran’s stammering.

Ciaran has good attention for tasks he enjoys. He sometimes gets over excited with some kinesthetic tasks, or impatient with games he enjoys less, but still participates with some additional support and verbal and physical cues to attend.

Goals

Ultimate Goal

Long Term Goal One

Long Term Goal: Two

Critical Reflection: Goals Included Ciaran’s preschool or future school?Ciaran began to show evidence of awareness at

his last session. May need to add goals around addressing secondary behaviours.

• Evidence base currently equivocal on the best approach to therapy for preschoolers: direct or indirect? Test and trial method therefore taken

Service Delivery

Direct TherapyHierarchical: built up from

Ciaran identifying all the different types of talking, and naming what talking the therapist used (to build objective awareness of talking styles)…

…to using smooth talk. Starting at one word level, achieving SLT-judged stability at this level before advancing to levels of increasing length and complexity.

Indirect Therapy Idea is to build a repertoire of

ideas, techniques and environmental modifications for Ciaran’s mum and family to use.

Supported with Palin PCI programme take-home handouts.

Strategies: slowing rate, reducing language & syntax, time for everyone to talk, using special play times with Ciaran to focus on him & not his stuttering, creating opportunities for conversation with Ciaran, following Ciaran’s lead.

Critical Reflection: TherapyAdvantage that Mum very

dedicated to applying direct and indirect techniques at home, increasing chances of positive outcome for Ciaran.

Would every parent be this motivated?

Generalisation: how to achieve, how to measure? Mum completed indirect

therapy activities with Ciaran at home every day between sessions

Mum completed smooth talk practice with Ciaran very regularly between sessions

Mum reported on Ciaran’s progress during the week

A re-assessment of Ciaran’s Stuttering severity will be completed at the end of the block in order to determine change in fluency at spontaneous speech level.

Outcome and Efficacy Outcomes: Measured ability with

smooth talk at every session. Outcomes: Parent report, observation

of spontaneous speech & fluency Outcomes: retake of %SS at end of

block Efficacy measure: Ciaran currently

using age-appropriate speech processes (interdental /s/ & /z/). These processes may be compared before and after therapy. If they have not changed, this may help to show that the effect of therapy has been specific

Outcome Measures: So FarCiaran can now identify

six different types of talking and use six different types of talking at request with 100% accuracy. [Measures from session 3]

Built up to simple sentence level by the 5th session (7 steps along the 14 step hierarchy – Walton & Wallace, 1998).

Critical Reflections: generalisation, outcome & efficacyRetaking %SS has limitations: stuttering fluctuates

on a daily and weekly basis for Ciaran at present. Efficacy: there’s a chance these speech processes

may remediate naturally during the time Ciaran is in therapy.

Recommendations & Future PlansReview and monitor Ciaran’s fluency.At the end of the block, future plans will depend

on the extent to which Ciaran’s fluency has improved at the level of spontaneous speech.

Future significant transitions, encourage mum to stay aware. NB first noted appearance of stammer when Ciaran started preschool. Advice to future primary?

Consider having Ciaran meet another child who stutters; mum meet parents of child who stutters

What if the stuttering stays?Ciaran may be in the 1% of children whose

stuttering persists despite therapy – too early yet to tell

Necessary to re-advise Ciaran’s family with regards to uncertainty of whether the stuttering will stay or go, and support discussion of their feelings and anxieties around this.

DischargeThere is no standard length of time for therapy; it

should be suited to the individual needs of the child (Richels & Conture, 2007).

Discharge ought to occur when & if: Mum, family and school report consistent and

confident use of indirect therapy strategies for CiaranReport from family and/or school of significant

improvement in spontaneous fluencyReduced measure of %SS at spontaneous speech

level (equivocal reliability however due to fluctuation).

Prognosis – Chronic, or not?Ultimate deciding factor: time We’re not sure – yet!

Thank you! Any Questions?

ReferencesCott, C. (2004) Client-centred rehabilitation: client perspectives. Disability & Rehabilitation, 26(24) 1411 – 1422. Frymark, T., Venediktov, R. & Wang, B. (2010) Effectiveness of Interventions for Preschool Children with Fluency Disorders: A Comparison of Direct versus Indirect Treatments. Available online: [http://www.asha.org/policy/GL1995-00048/] Last Accessed: 01.06.2013Gottwald, S. (2010) Stuttering and Your Child: Questions and Answers. Memphis: Stuttering Foundation of America

ReferencesGuitar, B. (2013) Stuttering: An Integrated Approach to its nature and treatment. 4th Edition. Baltimore: Wolters Kluwer.Kelman, E. & Nicholas, A. (2008) Practical Intervention for Early Childhood Stammering: Palin PCI Approach. Milton Keynes: SpeechmarkMcCormack, J., and Worall, L (2008) ‘The ICF Body Functions and Structures related to speech-language pathology’ International Journal of Speech-Language Pathology :10,(1-2) 9-17

ReferencesNelson, L. (1985) Language formulation related to dysfluency and stuttering. In Stuttering Therapy: Prevention and Intervention with Children. Memphis: Stuttering Foundation of America. RCSLT, (2006 ) Communicating quality 3; RCSLT guidance on best practice in service organisation and provision; London. Stewart, T. & Turnbull, J. (2007) Working with Dysfluent Children: Practical Approaches to Assessment and Therapy. Revised Edition. UK: Speechmark

ReferencesYaruss, J., Coleman, C., & Hammer, D. (2006). Treating preschool children who stutter: Description and preliminary evaluation of a family-focused treatment approach. Language Speech and Hearing Services in Schools, 37, 118–136.Walton, P. & Wallace, M. (1998) Fun with Fluency: Direct Therapy with the Young Child. Arizona: Imaginart Ward, D. (2008). The aetiology and treatment of developmental stammering in childhood. Archives of Disease in Childhood, 93, 68–71.