JOURNAL CLUB PRESENTATION

DIFFERENTIAL DIAGNOSIS OF STUTTERING FOR FORENSIC PURPOSES

CAROL HUBBARD SEERY UNIVERSITY OF WISCONSIN MILWAUKEE AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY.VOL-14. 284-297.NOVEMBER 2005

GUIDE : KUNNAMPALLIL GEJO JOHN,MASLP

STUTTERING?
Stuttering is characterized by an abnormally high frequency or duration of stoppages in the forward flow of speech. These stoppages usually take the form of ( a ) repetition of sounds, syllables (b) prolongations of sounds (c ) blocks of air flow or voicing in speech. ANDREWS,HARRIS & WINGATE (1964 )

Stuttering is the involuntary disruption of a continuing attempt to produce a spoken utterance PERKINS,1990.

Types of Stuttering

Developmental, Psychogenic & Neurogenic

Developmental stuttering occurs because a childs neurological system is not ready for all of the language that they are trying to say. Neurogenic stuttering is a signal problem between the brain and the nerves or muscles controlling speech. Psychogenic stuttering originates in the area of the brain that directs thought and reasoning. Psychogenic stuttering is rare.

WHAT IS MALINGERING?

It is defined as the intentional production of the signs or symptoms of a physical or mental disorder usually for the purpose of personal gain (American Psychiatric Association ,1994)

DIFFERENTIAL DIAGNOSIS OF MALINGERING

Pure Malingering when all of an individuals symptoms are falsified. Partial Malingering when existing symptoms are exaggerated. Malingering is difficult to diagnose without objective evidence, especially when symptoms are emotional or mental.

SPECIAL CHALLENGES TO THE DETECTION OF MALINGERED STUTTERING

Differential diagnosis of malingered stuttering is particularly challenging because of the inherently variable occurrence of actual symptoms of the disorder. On the average, about 90% of speech by a person who stutters is usually fluent (Bloodstein, 1944,1995)

Speech-language clinicians may have encountered the term forensic only infrequently in reference to the application of scientific knowledge to legal cases.

FORENSIC ART
Forensic art is any art that aids in the identification, apprehension or conviction of criminal offenders or that aids in the location of victims or identification of unknown person. KAREN T.TAYLOR,2001

FORENSIC SCIENCE Forensic science is the recognition, identification, collection, individualization & interpretation of physical evidence and application of science and medicine for criminal and civil law or regulatory purpose. Forensic application has greater validity in speaker identification and speaker verification tasks in the field of Speech & Hearing.

Only a few published reports are available describing forensic application of knowledge related to stuttering and fluency disorders. A body of information concerning processes and procedures for conducting forensic fluency assessment is important because such cases put to the test our criteria for differential diagnosis, especially to distinguish possible malingering.

A differential diagnosis among developmental stuttering, psychogenic stuttering, neurogenic stuttering and malingered stuttering is necessary (Table) Developmental stuttering and malingering may share similar characteristics to the extent that the individual has an awareness of what to imitate.

TABLE
Characte ristic ONSET time

Developmen Neurogenic tal stg stg

Psychoge malinger nic stg ing

Childhood

Adulthood

Adult hood

Any age

type

Gradual or sudden

Sudden

Sudden

Gradual/ sudden Variety of situations

circumst

ances

Variety of Situations

Neurological impairment

Psycho emotional distress

Characte ristic LOCATIO N OF STG: Word/ utterance

Developmen Neurogenic tal stg stg

Psychoge malinger nic stg ing

Not mainly at initiation stutters through out an utteranc e Not mainly at initiatio n stutters through out words &uttera nce

Initial locations: Stg on last syllables/ words are rare

Not mainly at initiation stutters through out an utterances

Characte ristic *Content or function word

Developmen Neurogenic tal stg stg

Psychoge malinger nic stg ing

No pattern of stg location related to content/ function words No pattern of location related to content / function words

Stuttering is more on content word

No pattern of stg location related to content/ function words

Characte ristic

Developmen Neurogenic tal stg stg

Psychoge malinger nic stg ing

Absent, difficult y with eye contact

SECONDA RY BEHR sPresent,

difficulty with eye contact

Not common, maintains eye contact

Not common , maintain s eye contact, bizarre behr +

Characte ristic

Developmen Neurogenic tal stg stg

Mild to severe

FREQUEN Mild to severe CY OF STG:

Psychoge malinger nic stg ing

Mild to severe May tend to stutter too much

TYPES OF Variety of STG disfluency

types (core)

Variety of disfluency types

Variety Variety of of disfluen disfluenc cy y types( types syllable) ( atypical /stereo type)

Characte ristic

Developmen Neurogenic tal stg stg

Psychoge malinger nic stg ing NO adapta tion effect May not show

ADAPTATI May or ON may not EFFECT: occur

NO NO adaptation adaptat effect ion effect Unknown Unkno wn

CONSIST ENCY EFFECT :

Likely

Characte ristic

Developmen Neurogenic tal stg stg

VARIABIL Variable across ITY OF situations STG:

Less variable Less across variable situation

Psychoge malinger nic stg ing

May stutter too constan tly across situatio ns

EASIER SP TASK:

Usually improves

May/ may not improve

May/ may not improve

Stg is not apt to improve

Characte ristic

Developmen Neurogenic tal stg stg

Psychoge malinger nic stg ing

May/ may not improve May stutter/ report to stutter without improve ment in all these conditio ns

FLUENCY Improves/ INDUCIN eliminate Stg G CONDITI ONS

May/ may not improve

Characte ristic EXPERIEN CES WITH LISTENER S:

Developmen Neurogenic tal stg stg Past experienc es usually include listener harassme nt Usually has not felt harassed by listeners, but may be annoyed

Psychoge malinger nic stg ing Usually has not felt harasse d by listener s, but may be annoye d May not descri be experi ences of unwan ted listene r reactio ns

Characte ristic EMOTION AL RESPONS E TO STG:

Developmen Neurogenic tal stg stg Attitudes of anxiousne ss/ avoidance related to speech and stuttering Feels annoyed, but not anxious/ fearful about Stg

Psychoge malinger nic stg ing Often indiffer ent toward Stg May not have emotio nal reactio ns to spkg/ Stg

REVIEW OF LITERATURE

Bloodstein (1988) describe the case of a male in his early 30s,who stuttered and who was accused of an armed robbery. He concluded that the defendants response were typical of a person who stutters, and attorney suggested that the charges would probably be dropped.

Shirkey (1987) suggested several types of evidence that might be useful in the identification of malingered stuttering : Speech assessment under varying conditions - covert audio recordings - polygraph (lie detector) testing - independent testimony -school and medical records related to speech fluency - data regarding speech characteristics.

Silverman (2004) recommended two important elements in the identification of malingered stuttering. 1) data need to be obtained for the purpose of comparing case characteristics with known facts about stuttering. 2) even if the characteristics are consistent with known facts they must pass additional tests to confirm their integrity.

AIM OF THE STUDY

* The differential diagnosis of a fluency disorder, potentially malingered ,which was performed for the sake of a criminal defense investigation *It highlights the application of an assessment protocol for differential diagnosis of different types of stuttering

METHOD

PARTICIPANT: Defendant was a white male in his late 30s Spoke only American English, had dropped out school & completed equivalency diploma in early adulthood He had stuttered since childhood no family history of stuttering initial impression : severe degree of stuttering

SETTING & SCHEDULING speech was conducted at county jail in a small room the audio tape recorder (Marantz ModelPMd221) used to obtain data The assessment period was limited to a 2hr visit

PROCEDURES
Collection

of speech samples

1.spontaneous speech -core -accessory 2.oral reading series -adaptation -consistency -loci

 Observation

of other speaking conditions

1. unison reading 2. imitation of wds, phrases and sentences 3. samples of whispered, shouted &lipped speech 4. rote or automatic speech 5. therapeutic probes

 Evaluation

attitudes

of communication

1.interview 2.use of Modified Erickson scale

Case

history & background

1.interview 2.self reports of stg 3.jail inmate records 4.health/medical records 5.reports of outside informants

RESULTS

COLLECTION OF SPEECH SAMPLES

SPONTANEOUS SPEECH .core .accessory

104/100wds

50/100wds 54/100wds

ORAL READING

.adaptation
.consistency .loci

Severe stg, R1->39%,R2-> 34%,R3->39% R1&R2 ->4.9%, R1&R3->0% CI->51% 50%->cw& 25%->fw

OBSERVATION OF OTHER SPEAKING CONDITION

.Unison Severely .Imitation of stuttered wds,phrases& ssentences .samples of whispered, shouted &lipped speech .automatic speech .therapeutic probes

EVALUATION interview OF COMMUNICATI ON ATTITUDES Modified Erickson scale

-affective reactions of anger,embrass ment & aggravation -score 21(extreme stg) (nervousness& lack of confidence)

INTER RATER RESULT

.Words transcribed .core .accessory .cw&fw

Levels of agreement -96% -95% -100% -90&95%

CASE interview HISTORY (self) AND BACK GROUND INFORMA TION -Self report of stuttering variability

-onset:4.5 yrs (mother) -letters stuttered are, w,o,sh,s,z,m,n,b,d,y,l -Attend therapy at 7 yrs(one day) -Family history negative -Questionnaire regarding situational variability ( in 16th item dont know)

-Jail inmate -Diagnosis of brain records aneurysm -Speech impediment secondary to aneurysm

CASE HISTORY AND BACK GROUND INFORMAT ION

.Psychiatric diagnosis -organic affective disorder and depression -alert, coherent ,goal directed future oriented, no self injury - tearful, extremely anxious, mood up and down: -Speech: Severe and persistent stutter -Good eye contact -No mention of any period of fluent speech

CASE HISTORY -Health/ AND medical BACK records GROUND INFORMA TION -Outside informants

-Sort medical examination with the c/o of periods of losing consciousness -Had normally appearing vital signs, lungs and heart -MRI scan results: negative -Identification of potential witnesses that the defendants speech fluency at or near the time of the crime -Defendants physician report: he had severe stg & was unlikely to speak fluently during the crime

DISCUSSION

DIFFERENTIAL DIAGNOSIS OF THIS CASE The results were examined for the purpose of differential diagnosis among developmental, neurogenic, psychogenic stg and malingering .

Is it a developmental stg?
The defendant presented with several characteristics typical of true developmental stg : a) onset of stg early age b) evidence of core disfluency type c) sd / syllable repetitions d) typical description of personal experiences with stg

e) location of stg on initial sds of wds and on expected grammatical structures of sp. The results of the sp-lg assessment taken together with other evidence suggested that the defendant was probably truthful about being a person who stutters

Is it a psychogenic stg?

Jail records were revealed about potential psychiatric concerns Anxiety and depression Sd / Syllable repetitions Stg worsens with easier tasks stg is not improved with either rhythm or whispering Adaptation effect is absent

Relaxed eye contact Struggle / bizarre behaviors unrelated to sp or stg are often seen CHARACTERISTICS WHICH WERE NOT CORRELATING WITH THIS CASE:a) psychogenic stg is usually acquired after adolescence b) the emotional response tends to be indifferent towards stg

The consistent characteristics didnt rule out the possibility that an overlay of psychogenic stg might be involved; nonetheless, they were sufficient to raise doubts.

Is it neurogenic stg?

Stg usually consistent across sp tasks and conditions Secondary symptoms not typical No adaptation effect Disfluency on highly automatic sp tasks Disfluency occurring not only at the initiation of utterances The above mentioned characteristics were also seen in malingering

CHARACTERISTICS WHICH WERE NOT CORRELATING WITH THIS CASE:

The onset of neurogenic stg is usually after adolescence It may occur at any location within words Emotional reaction annoyance rather than anxiety Defendant reported invariable stg Diagnosis of neurogenic stg must be based on confirmed neurological impairment

Is it malingering?

Although evidence supported an authentic case of developmental stg, other results suggested partial malingering in the form of exaggeration of stg and accompanying symptoms. Multiple characteristics were notably severe and atypical.

There were at least 6 characteristics led to the conclusion of partial malingering:1) the defendant displayed a high level of stg severity during the sp sampling. 2) the location and pattern of stg behavior were atypical eg: spontaneous sp sample: Well this umuh umuh umuh umuh umuh umuh uuuuumuh uuumuh uuumuh uuumuh uuum uuum kid that its a its a big long thi-thing-thing

3) absence of adaptation and consistency effect during oral reading 4) lack of improvement in any of the known fluency- inducing condition 5) relaxed and direct eye contact, even during the most severe stg moments 6) the contradictions between the reports made by others and the responses made by the defendant

The multiple testimonies regarding fluent speech by the defendant conflicted with his report and display of invariable stg during assessment and contributed to a conclusion that the defendant was probably malingering. Presumably, the defendant had motivation to seek release from criminal charges .

CONCLUSION

Evidence from sp-lg assessment as well as reported observation by others suggested that the defendant was similar to a person who stutter. Other evidence he had exaggerating symptoms. Partial malingering was suspected based on the absence of variability in stg as well as the contradiction between his claims of no stg variability through out his life.

IMPLICATIONS

Each component in the protocol for fluency assessment offered variable results contributing to the process of differential diagnosis Thorough knowledge of stg is the clinicians greatest asset in differential diagnosis and analysis of suspected malingering A person who is truly stg must not be suspected of feigning based on unique individual speech characteristics and/or the fact of variability of their disfluency.

FUTURE RESEARCH

Future studies are needed to examine the components of the assessment protocol and case-history questions to identify the elements that are most eliminating for various differential diagnosis purposes. Further research and understanding of the differential diagnosis of malingering is needed.

We need to garner and integrate as much knowledge as possible regarding the nature of stuttering, its variability and its subtypes to increase the accuracy of our differential diagnosis and improve our judgments of the false from the true.

LIMITATIONS OF THE STUDY

This is a single case study. The assessment didnt include questionnaire regarding situational variability. In this study they have not mentioned any stuttering assessment scale for rating his stuttering severity.