Client is an 8.5 year old bilingual boy referred for treatment of a moderate fluency disorder characterized by repetitions, prolongations, and blocks. He has a history of sound distortions that were resolved, as well as recurrent ear infections. Evaluation found moderately severe stuttering involving sound and word repetitions, with concomitant behaviors like tension. Testing found awareness of his stuttering impacts his experiences at school. Treatment is recommended to teach fluency techniques and address attitudes, with a good prognosis given his age and motivation.

1. Boston University
Rehabilitation Services
Academic Speech and Language Center
Name: Client
Clinician: Christina Deery, BS
Supervisor: Diane Parris, MS, CCC/SLP, BRS/FD
Presenting Problem
Client, an 8.5 years old bilingual male, presents with a moderate fluency disorder
characterized by whole and part word repetitions, prolongations, and blocks.
Concomitant behaviors include audible inhalations, poor eye contact, moving hands
about the face, foot tapping, and noticeable tension in the neck muscles. Client was
referred to the Boston University Speech and Language Center by Joseph Dorko, MS,
CCC/SLP at Boston Medical Center where an initial evaluation was conducted on
December 1, 2006. This evaluation indicated the presence of a fluency disorder and
recommended treatment at this facility.
History
The following information was obtained from case history form and parent interview
conducted on February 2, 2007 with Client’s father. Previous evaluations addressing
articulation, voice, and fluency concerns have been conducted at Boston Medical Center
(December 2006), Massachusetts General Hospital (July 2003, May 2004) and through
the XX public school system (March 2004). Past medical history and significant findings
from these evaluations have been included in this report.
Client is the first and only born child of Mr. & Mrs. XX. Due to the fact that Client was
born out of the country, there are no medical records available before January of 2003,
when he and his family moved to the United States. However, parent report and previous
evaluations indicate that labor and delivery as well as the initial neonatal period were
unremarkable. Client’s past medical history is remarkable for a submucous cleft and
recurrent otitis media, which was successfully treated with antibiotics and bilateral PE
tube placement in October 2002. He had a complete audiological evaluation in May
2003 with results suggesting normal hearing.
Developmental motor milestones were reported within the anticipated time frames.
Parent report indicates that Client received speech services in Columbia to resolve sound
distortions of the phonemes /s, z, sh/ and nasal emissions, difficulties consistent with the
diagnosis of submucous cleft palate. Client’s mother reports that she was pleased with
these services, and indicates that they were successful in resolving his misarticulations
and hypernasality.
Client currently resides in XX with his mother and father in a Spanish-speaking
household. Prior to moving to the United States at age 4, Client was a monolingual
Spanish speaker, and had limited exposure to English. Upon arriving in America, he was
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2. enrolled in Kindergarten at the William McKinley School in MA in an English-speaking
classroom.
Client is currently in the third grade at XX Elementary School. Case history indicated
above average performance in history, mathematics, and science, and below average
performance in reading and language arts. Client receives special services in reading
after school.
Client’s father reports that Client is a respectful and smart boy who enjoys playing soccer
and riding his bike. His parents feel that he has adjusted well to living in the United
States, and has strong social and peer relationships.
Previous Evaluations
An evaluation at Massachusetts General Hospital XX Healthcare Center (MGH) in July
2003 revealed sound distortions of /s, sh, z/, and the presence of a mild/moderate fluency
disorder characterized by sound prolongations and word/phrase repetitions. Services
were rendered at MGH for two sessions before Client was discharged to the XX public
school system.
An evaluation within the XX public school system was conducted in March 2004 based
on recommendations from MGH. Vocal quality and fluency of speech were judged to be
within normal limits during this evaluation. Mildly impaired speech intelligibility was
observed in spontaneous speech, and was thought to be caused by rapid speech rate and
final sound/syllable deletions. Articulation testing revealed substitutions of f/th
(unvoiced) in all positions of words, and b/v in the medical position of words. Based on
the findings of this evaluation, direct speech and language services were not
recommended through the public school system. Fluency and vocal quality did not
appear to be interfering with Client’s academic performance or peer interactions.
A follow-up evaluation at MGH in May 2004 was conducted to address continued parent
concerns regarding fluency. At this time, Client’s mother hoped to re-initiate services
through MGH since Client did not qualify for services through the public school. Results
of this evaluation indicated the presence of a moderate/severe fluency disorder,
characterized by sound/syllable repetitions, interjections, and blocks. Secondary
behaviors included facial grimacing and body movements. Avoidance behaviors
included changing words mid sentence. Voice, pragmatic, and receptive and expressive
language skills were judged to be within normal limits. Client’s sound distortions and
hypernasal voice quality appeared at that time to have resolved. As a result of this
testing, individual therapy was recommended. Two sessions were attended before Mr.
and Mrs. Cardona reported seeking other services to better match their child’s needs and
learning style.
Client was seen for a fluency evaluation at Boston Medical Center in December 2006
following a referral from Client’s pediatrician, Dr. S. At the time of this evaluation,
Client’s mother was noted to be increasingly concerned about Client’s fluency, which she
felt had been gradually increasing in frequency and severity. She also indicated that
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3. Client was being teased by his classmates, and had several negative experiences in the
classroom related to stuttering. The findings of this evaluation were consistent with the
previous evaluation at MGH. Results indicated the presence of a moderate/severe
fluency disorder characterized by part/whole word repetitions of 2-3 iterations,
prolongations, and blocks with some secondary and avoidance behaviors evident. Based
on this evaluation, it was recommended that Client receive speech services through the
Boston University Clinic.
Behavioral Observations
Client is a polite and friendly boy who cooperated throughout today’s evaluation. He
spoke openly about his stuttering, and was easily engaged in conversation about school
and sports. Today’s evaluation is felt to be a reliable representation of his speech and
fluency behavior.
Fluency of Speech
The Stuttering Severity Instrument for Children and Adults, Third Edition (SSI-3) was
administered to Client to evaluate the severity, frequency and concomitant secondary
behaviors associated with his disfluencies. Two speaking situations were analyzed
including a picture description task and an age appropriate oral reading sample for a total
300 syllables. Client received a total overall score of 27 on this measure out of a possible
56 which corresponds with a moderately severe rating when Client’s score is compared to
other school age children who stutter. Disfluencies consisted primarily of sound
repetitions, whole and part word repetitions of on average two iterations, prolongations,
and blocks. Several disfluencies were noted to occur in clusters (i.e. prolongation +
block, sound repetition + word repetition). The average length of Client’s three longest
stuttering events was 1 second. Concomitant behaviors associated with Client’s
stuttering events included noisy breathing, poor eye contact, visible neck tension, and
movements of the extremities (including moving hands about the face and foot tapping
and swinging). In conversational speech, Client was noted to use a high frequency of
interjections (i.e. uh, um, like), and often included a prolonged and audible starter to the
initial position of words (i.e. mand, mbut, hdo) during which visible tension in the
neck was observed. Frequent and quick inhalations as well as poor breath support were
also observed on some occasions. Two instances of word substitutions were noted in the
reading passage indicating the possible presence of avoidance behaviors.
Client completed Brutten’s Children’s Attitude Test (CAT) with a score of 23 (mean
score of children who stutter = 16.7; mean score of children who do not stutter = 8.7).
This score indicates that Client has awareness and concern about speaking. Client’s
father has indicated that there have been some difficult situations in school, which have
escalated to the point of Client indicating to his parents that he does not want to go to
school anymore. Client has commented that children often imitate his speech, and make
fun of his stuttering. He has not developed any strategies for dealing with bullying.
Other
Informal observation of articulation indicated the presence of all age appropriate sounds
in connected speech. Vocal quality and resonance were judged to be within normal limits.
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4. An informal observation of Spanish and English language use in connected speech
indicates that it is within normal limits for conversational purposes. In addition, all
previous evaluations have found receptive and expressive language to be in the average
range. Reading skills were not assessed at the time of this evaluation as they are being
addressed in the school setting. Pragmatic skills were considered a strength.
Summary and Impressions
Client is a friendly and polite 8.5 years old bilingual boy who presents with a moderate
fluency disorder characterized by part and whole word repetitions, prolongations, clusters
and blocks. A high frequency of interjections and revisions were also noted in
conversational speech. Client appears to have awareness of his disfluencies and parent
report indicates that teasing and other negative speaking experiences are occurring more
frequently at school.
The prognosis for improved fluency of speech given appropriate intervention is excellent.
Positive prognostic indicators include Client’s age, supportive family, and motivation to
become fluent.
Recommendations
1. It is recommended that Client be seen for weekly individual fluency treatment
sessions. Sessions should be for one hour in length.
2. Treatment should include the following:
a. Increasing Client’s understanding of speech and disfluency. This will be addressed
though education of the basic anatomy for speech and identification of stuttering
moments.
b. Increasing fluency by teaching fluency enhancing techniques such as Easy Relaxed
Approach-Smooth Movement. This approach combines slight reduction in the rate of
speech and physical tension in speech muscles, and gradual movement into the rest of
sentences using normal speech pattern (Reardon & Yaruss, 2004). This approach will
be presented in a hierarchy beginning with words, moving to sentences and
eventually to structured conversational speech and reading. Eventually these new
behaviors should be transferred to “real-life” speaking situations that gradually
increase in difficulty.
c. Teaching stuttering modifications including pull-outs as a tool for Client to use during
moments of disfluency.
d. Counseling Client and his family about the nature of the disorder, feelings and
attitudes associated with stuttering, and available resources for children who stutter.
3. Testing of Client’s receptive and expressive language skills is recommended to
determine if there are additional factors contributing to his disfluency.
It has been a pleasure to work with Client and his family. Please feel free to call with
parental consent for further information: 617-353-7479.
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5. Christina Deery, BS Diane Parris, MS CCC/SLP, BRS-FD
Client File #: