differential diagnosis of stuttering for forensic purposes/journal club presentation/ kunnampallil...

7/27/2019 DIFFERENTIAL DIAGNOSIS OF STUTTERING FOR FORENSIC PURPOSES/JOURNAL CLUB PRESENTATION/ KUNNAMPALLIL GEJO

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JOURNAL CLUB

PRESENTATION

DIFFERENTIAL DIAGNOSIS OFSTUTTERING FOR FORENSIC PURPOSESCAROL HUBBARD SEERY

UNIVERSITY OF WISCONSIN MILWAUKEE

AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY.VOL-14. 284-297.NOVEMBER 2005

GUIDE : KUNNAMPALLIL GEJO JOHN,MASLP


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STUTTERING?

Stuttering is characterizedby an abnormally high frequency orduration of stoppages in the forward flow

of speech. These stoppages usually takethe form of ( a ) repetition of sounds,syllables (b) prolongations of sounds (c )

blocks of air flow or voicing in speech.ANDREWS,HARRIS & WINGATE (1964 )


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Stuttering is the involuntarydisruption of a continuing attempt toproduce a spoken utterance

PERKINS,1990.


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Types of Stuttering

Developmental, Psychogenic & NeurogenicDevelopmental stuttering occurs because achilds neurological system is not ready for all ofthe language that they are trying to say.Neurogenic stuttering is a signal problembetween the brain and the nerves or musclescontrolling speech.Psychogenic stuttering originates in thearea of the brain that directs thought andreasoning. Psychogenic stuttering is rare.


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WHAT IS MALINGERING?

It is defined as the intentional productionof the signs or symptoms of a physical ormental disorder usually for the purpose of

personal gain (American PsychiatricAssociation ,1994)


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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 withoutobjective evidence, especially whensymptoms are emotional or mental.


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SPECIAL CHALLENGES TO THE DETECTIONOF MALINGERED STUTTERING

Differential diagnosis of malingeredstuttering is particularly challenging

because of the inherently variableoccurrence of actual symptoms of thedisorder.

On the average, about 90% of speech bya person who stutters is usually fluent(Bloodstein, 1944,1995)


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Speech-language clinicians may haveencountered the term forensic only

infrequently in reference to the application

of scientific knowledge to legal cases.

FORENSIC ARTForensic art is any art that aids in theidentification, apprehension or conviction

of criminal offenders or that aids in thelocation of victims or identification ofunknown person.

KAREN T.TAYLOR,2001


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FORENSIC SCIENCE

Forensic science is the

recognition, identification, collection,individualization & interpretation ofphysical evidence and application of

science and medicine for criminal and civillaw or regulatory purpose.

Forensic application has

greater validity in speaker identificationand speaker verification tasks in the fieldof Speech & Hearing.


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Only a few published reports are availabledescribing forensic application of

knowledge related to stuttering andfluency disorders.

A body of information concerning

processes and procedures for conductingforensic fluency assessment is importantbecause such cases put to the test our

criteria for differential diagnosis, especiallyto distinguish possible malingering.


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A differential diagnosis among developmental

stuttering, psychogenic stuttering, neurogenicstuttering and malingered stuttering is necessary(Table)

Developmental stuttering and malingering may

share similar characteristics to the extent thatthe individual has an awareness of what toimitate.


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TABLECharacte

ristic

Developmen

tal stg

Neurogenic

stg

Psychoge

nic stg

malinger

ing

ONSET

time

type

circumstances

Childhood

Gradual orsudden

Variety of

Situations

Adulthood

Sudden

Neurologicalimpairment

Adult hood

Sudden

Psychoemotionaldistress

Any age

Gradual/sudden

Variety ofsituations


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.Characte

ristic

Developmen

tal stg

Neurogenic

stg

Psychoge

nic stg

malinger

ing

LOCATION OFSTG:

Word/utterance

Initiallocations:

Stg on lastsyllables/

words arerare

Not mainlyat initiationstuttersthrough out

anutterances

Notmainly atinitiationstutters

throughout anutterance

Notmainlyatinitiatio

nstuttersthroughout

words&utterance


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.

Characteristic

Developmen

tal stg

Neurogenic

stg

Psychoge

nic stg

malinger

ing

*Contentorfunctionword

Stutteringis more oncontentword

No patternof stglocationrelated tocontent/

functionwords

Nopatternof stglocationrelated

tocontent/functionwords

Nopatternoflocationrelated

tocontent/function

words


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.

Characteristic

Developmen

tal stg

Neurogenic

stg

Psychoge

nic stg

malinger

ing

SECONDARY BEHR sPresent,

difficultywith eye

contact

Notcommon,maintains

eye contact

Notcommon,

maintains eyecontact,bizarrebehr +

Absent,difficulty with

eyecontact

h l

h l


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.

Characteristic

Developmen

tal stg

Neurogenic

stg

Psychoge

nic stg

malinger

ing

FREQUEN

CY OFSTG:

TYPES OFSTG

Mild to

severe

Variety ofdisfluencytypes

(core)

Mild to

severe

Variety ofdisfluencytypes

Mild to

severe

Varietyofdisfluenc

y types(syllable)

May

tend tostuttertoomuch

Varietyofdisfluencytypes

(atypical/stereotype)

h l

h l


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.

Characteristic

Developmen

tal stg

Neurogenic

stg

Psychoge

nic stg

malinger

ing

ADAPTATIONEFFECT:

CONSISTENCYEFFECT :

May ormay notoccur

Likely

NOadaptationeffect

Unknown

NOadaptation

effect

Unknown

NOadaptation

effect

Maynot

show

h l

N i h li


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.

Characteristic

Developmen

tal stg

Neurogenic

stg

Psychoge

nic stg

malinger

ing

VARIABIL

ITY OFSTG:

EASIERSP TASK:

Variable

acrosssituations

Usuallyimproves

Less variable

acrosssituation

May/ maynot improve

Less

variable

May/may notimprove

May

stuttertooconstantly

acrosssituations

Stg isnot apttoimprove

Ch D l

N i P h li


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.

Characteristic

Developmen

tal stg

Neurogenic

stg

Psychoge

nic stg

malinger

ing

FLUENCYINDUCINGCONDITIONS

Improves/eliminateStg

May/ maynot improve

May/may notimprove

Maystutter/reportto

stutterwithoutimprovement inalltheseconditions

Characte Developmen

Neurogenic Psychoge malinger


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.

Characte

risticDevelopmen

tal stgNeurogenic

stgPsychoge

nic stgmalinger

ing

EXPERIEN

CESWITHLISTENERS:

Past

experiences usuallyincludelistenerharassment

Usually

has notfeltharassedbylisteners,but maybe

annoyed

Usually

has notfeltharassed bylisteners, butmay be

annoyed

May

notdescribeexperiencesofunwan

tedlistenerreactio

ns

Ch D l

N i P h li


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.

Characte

ristic

Developmen

tal stg

Neurogenic

stg

Psychoge

nic stg

malinger

ing

EMOTION

ALRESPONSE TOSTG:

Attitudes

ofanxiousness/avoidancerelated tospeechand

stuttering

Feels

annoyed,but notanxious/fearfulabout Stg

Often

indifferenttowardStg

May

nothaveemotionalreactions tospkg/

Stg


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REVIEW OF LITERATURE

Bloodstein (1988) describe the case of amale in his early 30s,who stuttered andwho was accused of an armed robbery. He

concluded that the defendants responsewere typical of a person who stutters, andattorney suggested that the charges

would probably be dropped.


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Shirkey (1987) suggested several types of

evidence that might be useful in theidentification of malingered stuttering : Speechassessment under varying conditions

- covert audio recordings

- polygraph (lie detector) testing- independent testimony

-school and medical records related tospeech fluency

- data regarding speech characteristics.


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Silverman (2004) recommended twoimportant elements in the identification ofmalingered stuttering.

1) data need to be obtained for thepurpose of comparing case characteristicswith known facts about stuttering.

2) even if the characteristics are consistentwith known facts they must passadditional tests to confirm their integrity.


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AIM OF THE STUDY

* The differential diagnosis of a fluencydisorder, potentially malingered ,whichwas performed for the sake of a criminaldefense investigation

*It highlights the application of anassessment protocol for differentialdiagnosis of different types of stuttering


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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


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SETTING & SCHEDULING

speech was conducted at county jail in

a small room

the audio tape recorder (MarantzModelPMd221) used to obtain data

The assessment period was limited

to a 2hr visit


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PROCEDURES

Collection of speech samples1.spontaneous speech

-core-accessory

2.oral reading series

-adaptation-consistency

-loci


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Observation of other speaking conditions

1. unison reading2. imitation of wds, phrases and sentences3. samples of whispered, shouted &lipped

speech4. rote or automatic speech

5. therapeutic probes

E l ti f i ti


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Evaluation of communicationattitudes

1.interview2.use of Modified Erickson scale

Case history & background1.interview

2.self reports of stg

3.jail inmate records4.health/medical records

5.reports of outside informants


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RESULTS

COLLECTION SPONTANEOUS 104/100wds


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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


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OBSERVATIONOF OTHER

SPEAKINGCONDITION

.Unison

.Imitation of

wds,phrases&

ssentences

.samples of

whispered,shouted &lippedspeech

.automatic

speech

.therapeutic

probes

Severely

stuttered

EVALUATION interview -affective reactions


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EVALUATIONOFCOMMUNICATI

ON ATTITUDES

interview

ModifiedEricksonscale

-affective reactionsof anger,embrass

ment & aggravation

-score 21(extremestg)

(nervousness&

lack of confidence)

INTER RATER

RESULT

.Wordstranscribed

.core

.accessory

.cw&fw

Levels of agreement

-96%-95%

-100%

-90&95%

CASE interview -onset:4 5 yrs (mother)


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CASEHISTORY

AND

BACKGROUNDINFORMATION

interview

(self)

-Self reportof stutteringvariability

-Jail inmaterecords

-onset:4.5 yrs (mother)

-letters stuttered are,

w,o,sh,s,z,m,n,b,d,y,l

-Attend therapy at 7yrs(one day)

-Family history negative

-Questionnaire regardingsituational variability

( in 16th itemdont know)

-Diagnosis of brainaneurysm

-Speech impediment

secondary to aneurysm

CASE


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CASEHISTORYAND BACK

GROUNDINFORMATION

.Psychiatric diagnosis

-organic affective disorder an

depression-alert, coherent ,goal directedfuture oriented, no self injury

- tearful, extremely anxious,mood up and down:

-Speech: Severe andpersistent stutter

-Good eye contact

-No mention of any period offluent speech

CASE


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CASEHISTORY

AND

BACKGROUNDINFORMATION

-Health/medical

records

-Outsideinformants

-Sort medical examination withthe c/o of periods of losingconsciousness

-Had normally appearing vitalsigns, lungs and heart

-MRI scan results: negative

-Identification of potentialwitnesses that the defendantsspeech fluency at or near thetime of the crime

-Defendants physician report:he had severe stg & wasunlikely to speak fluently duringthe crime


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DISCUSSION

DIFFERENTIAL DIAGNOSIS OF THIS

CASE

The results were examinedfor the purpose of differential diagnosisamong developmental, neurogenic, psychogenic stgand malingering.

d l l


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Is it a developmental stg?

The defendant presented with severalcharacteristics typical of true developmentalstg :

a) onset of stg early age

b) evidence of core disfluency type

c) sd / syllable repetitions

d) typical description of personalexperiences with stg


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e) location of stg on initial sds of wdsand on expected grammaticalstructures of sp.

The results of the sp-lg assessment takentogether with other evidence suggested that the

defendant was probably truthful about being aperson who stutters


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Is it a psychogenic stg?

Jail records were revealed about potentialpsychiatric 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


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Relaxed eye contact

Struggle / bizarre behaviors unrelated to

sp or stg are often seenCHARACTERISTICS WHICH WERE

NOT CORRELATING WITH THIS

CASE:-a) psychogenic stg is usually acquired

after adolescence

b) the emotional response tends to beindifferent towards stg


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The consistent characteristics didnt ruleout the possibility that an overlay of

psychogenic stg might be involved;nonetheless, they were sufficient to raisedoubts.


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Is it neurogenic stg?

Stg usually consistent across sp tasks andconditions

Secondary symptoms not typical

No adaptation effect Disfluency on highly automatic sp tasks

Disfluency occurring not only at the

initiation of utterancesThe above mentioned characteristics were also

seen in malingering

CHARACTERISTICS WHICH WERE NOT


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CHARACTERISTICS WHICH WERE NOTCORRELATING WITH THIS CASE:-

The onset of neurogenic stg is usually afteradolescence 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


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Is it malingering?

Although evidence supported an authenticcase of developmental stg, other resultssuggested partial malingering in the form

of exaggeration of stg and accompanyingsymptoms.

Multiple characteristics were notably

severe and atypical.


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There were at least 6 characteristics led tothe conclusion of partial malingering:-

1) the defendant displayed a high levelof stg severity during the sp sampling.

2) the location and pattern of stg

behavior were atypicaleg: spontaneous sp sample:

Well this umuh umuh umuh umuh umuhumuh uuuuumuh uuumuh uuumuhuuumuh uuum uuum kid thatits a its abig long thi-thing-thing

3) b f d i d i


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3) absence of adaptation and consistencyeffect during oral reading

4) lack of improvement in any of theknown fluency- inducing condition

5) relaxed and direct eye contact, evenduring the most severe stg moments

6) the contradictions between the reportsmade by others and the responsesmade by the defendant


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The multiple testimonies regarding fluentspeech by the defendant conflicted with

his report and display of invariable stgduring assessment and contributed to aconclusion that the defendant wasprobably malingering.

Presumably, the defendant had motivationto seek release from criminal charges .


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CONCLUSION

Evidence from sp-lg assessment as well asreported observation by others suggested thatthe defendant was similar to a person whostutter.

Other evidence he had exaggeratingsymptoms.

Partial malingering was suspected based on theabsence of variability in stg as well as thecontradiction between his claims of no stgvariability through out his life.


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IMPLICATIONS

Each component in the protocol for fluencyassessment offered variable resultscontributing to the process of differentialdiagnosis

Thorough knowledge of stg is the cliniciansgreatest asset in differential diagnosis andanalysis of suspected malingering

A person who is truly stg must not besuspected of feigning based on uniqueindividual speech characteristics and/or the factof variability of their disfluency.


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FUTURE RESEARCH

Future studies are needed to examine thecomponents of the assessment protocoland case-history questions to identify the

elements that are most eliminating forvarious differential diagnosis purposes.

Further research and understanding of the

differential diagnosis of malingering isneeded.


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We need to garner and integrate as muchknowledge as possible regarding thenature of stuttering, its variability and its

subtypes to increase the accuracy of ourdifferential diagnosis and improve our

judgments of the false from the true.


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LIMITATIONS OF THE STUDY

This is a single case study.

The assessment didnt includequestionnaire regarding situational

variability.

In this study they have not mentioned anystuttering assessment scale for rating his

stuttering severity.


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differential diagnosis of stuttering for forensic purposes/journal club presentation/ kunnampallil...

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