INTRODUCTION

Differential diagnosis is an important aspect of successful treatment in fluency disorders. Many families believe that all fluency disorders are classified as stuttering. Professionals who treat fluency disorders are well aware, however, that there are many other types of fluency disorders. These include cluttering, psychogenic stuttering, neurogenic stuttering and other disorders that appear on the surface to be stuttering, but are different in their symptoms, course of development, and treatment (ASHA, 1999). One of these fluency disorders that has gained attention in the past few years is associated with Tourette's Syndrome.

Tourette's Syndrome is a motor disorder characterized by the presence of motor or vocal tics. The diagnosis is confirmed by the presence of these tics and is marked by an impairment to social and/or occupational functioning. Onset is typically before the age of 18 (DSM-IV, American Psychiatric Association, 1994). It has been suggested that some symptoms associated with developmental stuttering may also be associated with Tourette's Syndrome (Abwender et al., 1998). These symptoms specifically include motor tics. Other symptoms of stuttering (i.e., secondary or associated characteristics) have also been documented in Tourette's Syndrome. These behaviors can include the aforementioned vocal tics, but can also include behaviors such as eye deviation, and/or lip raising (Conture & Kelly, 1991). Due to overlapping symptoms, it is often difficult to separate stuttering from other neurological, psychological, or motor speech disorders (Van Borsel & Vanryckeghem, 2000). Even when a correct diagnosis is made, there is limited data on how these clients respond to treatment or what is the best course of action to take in therapy.

The purpose of this paper is to present two different case studies that have been diagnosed with fluency disorders associated with Tourette's Syndrome. Both subjects are minors and will be referred to by pseudonyms throughout this paper. The first case, was referred from a Tourette's Syndrome clinic, and therefore had already received the proper diagnosis. The main function of the first case presentation will be to emphasize the planning and goal setting. The second case was referred by his mother, and was not diagnosed with Tourette's Syndrome. The emphasis for the second case presentation will be on the differential diagnosis and referral.

Case #1

John Doe is an 8-year-old boy who was referred for a speech evaluation by his neurologist due to concerns regarding an inability to produce clear and fluent speech. John's mother reported that he has stuttered since he began speaking but the behaviors have increased recently. There is no significant family history of stuttering.

Medical/ Developmental/Educational and Social History:

Mr. and Mrs. Doe reported that John's medical history is remarkable for allergies, chronic colds, several ear infections and a right-sided hernia. John was diagnosed with Tourette's Syndrome and Attention Deficit Hyperactivity Disorder (ADHD) at six years of age by his neurologist. John is currently taking .5 mg. of Risperdal daily to control his tic behaviors. His tics began at age five with throat clearing, teeth clenching, eye blinking and eventual facial grimacing. John lives with his parents and an older sister. Mr. and Mrs. Doe describe him as inquisitive, energetic, sensitive and interesting. They feel that John's speech pattern is beginning to prevent him from participating in activities and are concerned that the recent changes may lead to increased teasing, reduced self-esteem and problems with peers. John recently completed first grade. Throughout the previous school year, John appeared disinterested in the curriculum. His teachers reported that he had difficulty staying on task and frequently was distracted. He has reportedly demonstrated difficulty following multi-step directions. During the past school year, he received pull-out speech therapy and tutoring in reading.

Results from academic testing suggested that John's intellectual abilities fall within the Average Range. However, some specific areas of difficulty were noted including the processing of spoken language, phonological awareness skills, linguistic organization and formulation skills and verbal and working memory abilities. Therefore, John was reported to show signs of a language-based learning disability.

John was also evaluated and followed by a speech and language pathologist, who indicated delayed expressive and receptive language skills. Specific weaknesses included his ability to follow directions presented verbally, his knowledge of basic linguistic concepts and his ability to formulate and organize language. Mr. and Mrs. Doe reported that the school-based therapy addressed ways to present information to John and strategies to assist him in sequencing and processing information. The school based clinician was not concerned with John's disfluency since she felt the behaviors were simply part of his Tourette's Syndrome and could not be changed, according to Mrs. Doe.

Current Speech Evaluation:

John was referred for a follow-up speech evaluation from the Tourette's Clinic at a major medical center. The findings of the current evaluation are summarized below:

Behavior: During the evaluation, John was an active participant and was willing to participate in conversation with a minimal amount of coaxing. He demonstrated difficulty staying on task and frequently produced tangential information. It was difficult to follow his line of thought at times given that he frequently produced disorganized and fragmented language.
Language: Although the primary concern of this evaluation was fluency, John's language skills were screened. Results of this screening are commensurate with earlier cognitive-linguistic testing and suggest that John's expressive and receptive language abilities are delayed.
Speech/Fluency: Throughout the evaluation, John demonstrated behaviors that significantly reduced his intelligibility. He demonstrated increased effort during speech and appeared to be struggling with his ability to express himself. His primary speech behaviors included:

• Phrase repetitions
• Rapid speech rate with minimal pausing
• Decreased articulatory precision
• Decreased eye contact
• Restarts and revisions
• Frequent interjections/fillers
• Abandoned thoughts/ideas
• Aggressive verbal interactions
• Significant disregard for his communicative partner.

Throughout the evaluation, John demonstrated behaviors consistent with the diagnosis of a cluttering disorder. These include the fast rate, dysrythmic, unorganized and frequently inarticulate speech with no apparent awareness of the problem. John demonstrated sporadic spurts of speech, a jerky breathing pattern, slurred articulation, distractibility, poor attention span, poor concentration and a lack of self-awareness or concern with inappropriateness of his speech behaviors. John also demonstrated vocal and motor tics that appear to be part of his Tourette's Syndrome. These included facial twitching, eye movements, blinking and jerking his hands and feet. He also presented with certain ritualistic behaviors or obsessions throughout the session. These include facial rubbing and continuously asking when the session will be over.

Summary/Recommendations:

John is an 8-year-old boy who was referred for a speech evaluation due to concerns regarding the production of fluent speech. In addition to individual therapy, it was suggested that part of his intervention eventually take place with peers who demonstrate similar characteristics. The desensitization that is gained by such a meeting may reduce anxiety and promote more fluent speech. In addition, this group would serve as an ideal place to promote socializing skills while working on conversational skills.

John should also receive individual therapy for 60 minutes per week. Given his distractibility and difficulty with following directions, intervention will take place during shorter, more frequent sessions to ensure John's comprehension and mastery of techniques. The clinician will attempt to simplify directions, provide repetition of all ideas/concepts, provide written descriptions and visual aids whenever possible and take advantage of the family's willingness to participate in therapy. The goals of therapy should include attempts:

Therapy should involve the entire family and work specifically on:

• Educating the family on what is occurring and how that will affect John's ability to perform certain tasks in everyday situations.
• Educating the family on stuttering on what they can do to assist John in the therapy process.

As John has experienced difficulties in the classroom environment, therapy should address John's needs in that specific environment. Goals to assist in this area include:

• Train the teachers, administration and support staff what they can and should do when interacting with John. For example, teach them to give John the time to finish his thoughts. Instruct them to keep eye contact and not to treat John any differently than they would any other child.
• Educate John's classmates on Tourette's Syndrome and stuttering. When children understand what is behind the atypical behaviors, they will be less likely to tease or stare at their peer.

Epilogue:

John is currently enrolled in speech therapy one time per week in a group with a peer demonstrating similar behaviors. The group works primarily on social interaction skills and identifying good speech habits. They work on topic maintenance skills, listening skills and turn taking. John's speech is becoming more fluid as he takes more time to organize and formulate his thoughts. John is beginning to show more confidence in his own abilities and is becoming more interactive and social. His family is highly involved in therapy and has been advocating for John with his teachers and the school administration.

Case # 2

James Q. Public is an 11-year-old boy who was referred for a speech evaluation by his mother secondary to a concern that the school-based services were not intense enough to foster true change. James's mother reported that he has stuttered since he began speaking but the behaviors have increased recently. There is no significant family history of stuttering.

Medical/ Developmental/Educational and Social History

According to Mrs. Public, James did not begin to stutter until he was 11 years old. His history includes an educational/medical diagnosis of "possible ADHD." James has an above average intelligence as measured by school psychologists, and is enrolled in the "gifted program" at his school. James takes no medications other than occasional medications for seasonal allergies. His language abilities are above expected levels as measured by standardized language tests. In addition, his conversational skills are judged to be adequate in dialogue situations. The chief compliant at the time of his referral to a university speech and hearing clinic was that his mother reported him to be "disfluent in all situations." He had received almost two years of fluency shaping therapy in the public school system, with little or no progress noted.

Current Speech Evaluation:

The current speech evaluation took place at a university speech, language and hearing center at the request of his mother who was concerned about the lack of his progress in stuttering therapy. The findings are summarized below:

Behavior During the evaluation, James was an active and willing participant. He openly discussed many topics with the clinician and was willing to participate in conversation without any coaxing. He demonstrated excellent language skills throughout the evaluation. He talked about books he had read and showed evidence of excellent written language skills through written narratives. He later informed the clinician that he enjoyed writing short stories. The quality of both written and oral narratives was excellent with above average organizational and vocabulary skills. Language: Since, the primary concern of this evaluation was fluency, and since James displayed such excellent language skills, no formal language testing was completed during this evaluation. Speech/Fluency: The results of the fluency evaluation revealed the presence of "disfluencies" in many different tasks and levels of linguistic length and complexity. Examples of these disfluency rates included:

• 9.2% disfluency rate during a word naming task,
• 0% disfluency during a sentence repetition task,
• 5.1% disfluency during a monologue task,
• 0% disfluency during a telephone conversation,
• 5.7% disfluency during a conversation with two strangers.

Upon first glance it might appear that this profile is that of an individual who stutters, however, more in-depth analysis of revealed:

• significant disfluencies, specifically vocal tics
• onset later in life
• inability to control vocal tics under conditions of behavioral instruction
• no change in stuttering behaviors after the use of multiple fluency induction techniques (e.g., DAF, masking, and rhythmic speech)
• no adaptation effect,
• an unusual type and distribution of disfluencies, that included many word and sentence medial disfluencies, and many word and sentence final disfluencies.

Summary/Recommendations:

This client was referred to a pediatric neurologist with suspicion of Tourette's Syndrome. The pediatric neurologist made the diagnosis of mild Tourette's Syndrome. This came within 24 days of his evaluation at the University of Louisiana at Lafayette's Speech, Language and Hearing Center.

Epilogue:

Following his diagnosis of mild Tourette Syndrome, James and his mother decided against pharmacological intervention. He returned to the university speech and hearing center where he began speech therapy with goals outlined to increase awareness of vocal tics, and control the disfluencies through cancellations, pullout, and preparatory sets. The client decreased his disfluencies to less than 2.5% in all situations after 1 and 1 /2 semesters of therapy at the university clinic. He has maintained these levels for over one year post dismissal and is happy with his current levels of fluency. According to parent reports, the symptoms associated with Tourette's Syndrome have not progressed.

Discussion

Both of these individuals came to speech and language centers for either a "second opinion" or a more in-depth evaluation. In both cases, it appears as if the family knew there was something affecting the child's speech, in addition to just stuttering. It is interesting to note that John already carried the diagnosis of stuttering/cluttering while James and his family were unaware of this diagnosis. In both cases, the importance of an in-depth evaluation with a carefully constructed intervention plan led to eventual gains in speech and language goals.

In summary, it is apparent that all cases referred to speech-language pathologists for stuttering, may indeed be something other than "just stuttering." There are documented cases in the literature of stuttering related to Tourette Syndrome disorders (Van Borsel & Vanryckeghem, 2000), Multiple Sclerosis (Mowrer & Younts, 2001), Parkinson's Disease (Goberman and Blomgren, 2003), and many other motor and neurological conditions (Helm-Estabrooks, 1999). It is indeed the job of the skilled speech-language pathologist to 1.) recognize these cases 2.) assess all contributing factors including speech, language, social, educational, and developmental aspects 3.) plan appropriate, individualized therapy strategies for the patient and their family, and 4.) make all necessary referrals for the total care of these individuals. We hope that these case studies will help families and clinicians in the accurate diagnosis and appropriate treatment for all types of fluency disorders.

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Goberman, A.M. & Blomgren, M. (2003). Parkinsonian speech disfluencies: effects of -dopa-related fluctuations. Journal of Fluency Disorders, 28, 55-70.

Helm-Estabrooks, N. (1999). Stuttering associated with acquired neurological disorders. In R.Curlee (Ed.), Stuttering and Related Disorders of Fluency. New York: Thieme Medical Publishers.

Mowrer, D.E. & Younts, J. (2001). Suden onset of expressive repetitions in the speech of a patient with multiple sclerosis: A case report. Journal of Fluency Disorders, 26, 269-310.

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Van Borsel, J., & Vanryckeghem, M. (2000). Dysfluency and phonic tics in Tourette syndrome: A case report. Journal of Fluency Disorders, 33, 227-240.

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September 1, 2003