(80 - 03) The importance of ongoing differential assessment and treatment for children who stutter

Abstract: Careful and ongoing assessment of a child’s overall communication development requires exploration of not only the pattern of fluency, but also other domains related to communication. The aim of the current case study was to examine the outcomes of ongoing differential assessment and treatment provided to a 5-year-old child who was referred to our clinic for treatment and had been diagnosed solely with stuttering. Although treatment initially included fluency support, later interventions focused on additional contributing factors to communication difficulties in three primary areas: executive functioning, language, and social-emotional capacities. Treatment was provided via telehealth with a strong client-clinician relationship at its core. According to standardized post-testing, this child no longer stutters and demonstrates significant improvements in all targeted areas. Ongoing differential assessment of potential internal and external contributing factors, including potential sub-clinical factors, is critical to effective treatment.

Summary of Presentation : Approximately 2% of children (age 3-17 years) stutter (Zablotsky et al., 2019) and research has shown that early intervention can prevent overlearned stuttering behaviors, which either reduces the severity or resolves stuttering entirely (Iverach et al., 2016; Rustin & Cook, 1995; Smith & Weber, 2017). Ongoing differential diagnosis can significantly change how clinicians approach communication difficulties experienced by children who stutter. This requires careful observation to identify issues that may extend beyond stuttering and then spending considerable time exploring those potential contributing factors. In fact, Briley & Ellis (2018) reported that nearly 52% of children who stutter (CWS) have at least one disabling developmental condition and that 29% have at least two conditions.
To account for individual variability and factors contributing to fluency, Chmela and Campbell (2014) adapted a diagram that depicts the child as a house existing in its environment (Anderson & Ofoe, 2019). In this schematic, the internal environment of the child is depicted as the house. The “foundation of the house” is executive functioning; the relevant “rooms of the house” include motor, sensory, cognitive, language, and social emotional capacities. The external environment around the house includes the core family and then the larger community of the child (e.g., school, sports teams, extended family, friends, etc.).
This retrospective case study is based on a child who was originally diagnosed with a moderate fluency disorder at the age of 5 years and 3 months. Initially, treatment centered on working with the parents to reduce communicative pressure in the home environment in order to support fluency. As the case unfolded, careful observations were made that led to the following additional primary targets: executive functioning, word retrieval, language formulation, and communicative confidence. In the house diagram, these areas are represented in the “foundation of the house” (executive functioning), the language “room” (word retrieval and language formulation) and the social emotional “room” (communicative confidence).
The external environment was one of the first targets. Many conversations were held with the parents to help reduce talking pressure. For example, the family worked on taking talking turns and reducing overall time pressures in daily routines, which included honoring transitions between daily activities. Reducing time pressure was accomplished in part by creating a written morning schedule and by establishing reliable evening patterns of activity. The child quickly responded to these simple interventions such that repetitions were significantly diminished early in treatment.
The next area addressed was executive functioning. As noted in the case history, this child had a genetic predisposition to executive functioning difficulties as there was a family history of attention deficit hyperactivity disorder (ADHD). Sessions often began with age-appropriate breathing exercises to promote regulation, which in turn facilitated the ability to attend to the activities of the session. Additionally, chewing gum was used for sensory input to facilitate regulation during most sessions. These interventions clearly helped him to regulate and to attend. In keeping with the observations of Smith and Weber (2017) and Karass et al. (2006), it was often noted that the child had very few dysfluencies in the sessions in which he was clearly regulated.
Over time, it was noticed that the child used excessive filler words to hold the conversational floor, which led to exploration and discovery of word retrieval difficulties. Semantic system support was then incorporated into intervention in the form of play. Semantic Feature Analysis (SFA) was one of the activities used to promote word retrieval by prompting the child to generate and compare features of two words in a category of interest to the child (Boyle, 2010). More specifically, features unique to each word were created and then a list of features common to both words in the category was also made to strengthen the semantic system. The Expanding Expression Tool (EET; Smith, n.d.) was also used to promote word retrieval by stimulating the semantic system.
Through careful observation over time, language formulation and sequencing of narratives also surfaced as additional communication challenges, though standardized testing had not indicated that these capacities were out of the typical range. Support was incorporated into therapy through a combination of carefully designed language formulation tasks that simultaneously strengthened the semantic system. These tasks often appeared to the child as natural conversation on specific topics of interest to him (e.g., events of the day, upcoming events, sports, etc.). Levels of language formulation and semantic complexity were systematically increased and decreased throughout the session to challenge the client while at the same time ensuring communicative success.
Lastly, communicative confidence was targeted throughout all of the sessions within the social emotional domain. At 5 years of age, this child was already shrugging and giving up on failed word retrieval attempts and turning to parents to fill in words. To help build confidence, the child often engaged in language formulation activities in which he “taught” the clinician about a topic unknown (or little known) to her. The child also taught younger siblings and family members about lessons learned in therapy (e.g., breathing exercises and taking thinking time). Confidence was also negatively affected by a few incidents of bullying on the school bus that took place over the course of treatment. Importantly, the central unconditional, genuine, and safe clinical relationship that was established early on which allowed the client and family to feel secure in discussing these hurtful circumstances, so that immediate problem-solving could take place.
Results of this case study highlight the importance of ongoing differential diagnosis and assessment. Posttests were performed by a graduate student clinician under the direct supervision of a licensed speech language pathologist (SLP) who specializes in fluency disorders and was not the treating SLP. This child was re-evaluated at the age of 9 years using standardized and non-standardized assessment.
In posttest assessment, no stutter-like dysfluencies or secondary behaviors were observed. Fluency posttest assessment revealed that this child used “other dysfluencies” 12.5% of the time in narrative form and 9% of the time in conversation, indicating his ongoing need for support in language formulation, not stuttering. Posttest assessment of language demonstrated a significant reduction in the gap that had been noted between pretest receptive and expressive language scores: a 4-point negligible gap was noted during post-testing as compared to the significant 13-point gap in pre-testing.
Overall, this child is no longer considered a person who stutters, which may not have been the case had he not received ongoing differential diagnosis and treatment. Although standardized fluency and language testing resulted in a singular diagnosis of moderate stuttering, assumptions were not made about what factors may be contributing to communication difficulties. Careful observations revealed critical subclinical deficits in language, executive functioning, and social emotional functioning.
Using tools such as the adapted diagram that depicts the child as a house existing in its environment (Anderson & Ofoe, 2019; Chmela & Campbell 2014) to account for individual variability and factors (including potentially subclinical factors) that contribute to fluency can be helpful in making these observations at the onset of therapy and over the course of therapy. In all cases, and especially in the case of children in early development, it is critical that we do not make assumptions based solely on standardized testing and that we understand that differential diagnosis and differential treatment are an ongoing and dynamic process.