3. Background to case:
Client: Ciaran
Gender: Male
Age: 4:6
Reason 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.
4. 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
5. 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.
6. History of Stammering
Length 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 time
Awareness of stammer: no awareness reported, nor
observed during sessions.
8. 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
10. Environmental Factors
Lives at home with mum, dad
and 8 y/o brother
Mum 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.
15. 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.
16. 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.
17. Diagnosis
Severe (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?
20. Risk Factors for Persistent
Stammer
Male
Positive Family History of S&L issues
Evidence 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).
23. Clinical Observations
Increasing 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.
28. 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
30. Direct Therapy
Hierarchical: 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.
31. 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.
32. Critical Reflection: Therapy
Advantage 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?
33. 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.
34. 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
35. Outcome Measures: So Far
Ciaran 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).
36. Critical Reflections: generalisation,
outcome & efficacy
Retaking %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.
37. Recommendations & Future Plans
Review 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
38. 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.
39. Discharge
There 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 Ciaran
Report from family and/or school of significant
improvement in spontaneous fluency
Reduced measure of %SS at spontaneous speech level
(equivocal reliability however due to fluctuation).
40. Prognosis – Chronic, or not?
Ultimate deciding factor: time
We’re not sure – yet!
42. References
Cott, 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: 01.06.2013
Gottwald, S. (2010) Stuttering and Your Child: Questions
and Answers. Memphis: Stuttering Foundation of America
43. References
Guitar, 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: Speechmark
McCormack, 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
44. References
Nelson, 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
45. References
Yaruss, 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.
