Question
My question is about a 13 year old student who had unintelligible speech as a preschooler, has had speech therapy since then, and now is judged as 70% intelligible to a familiar listener. He seems to have four contributing characteristics to his unintelli
Answer
The case you have presented is very complex and replete with various observations that seem to conflict in terms of any obvious diagnosis! I consulted with another SLP, Margaret Fein, whose special interest areas are different from mine in helpful ways for this case. We have a variety of questions, possible needs for referrals, and some guidance. If that, to you, seems to hit a brick wall, then a complete interdisciplinary evaluation would be essential.
Regarding your question as to whether this is "cluttering" behavior, I would say no. See David Daly's Predictive Cluttering Inventory (2006). This may, in fact, help guide you in adding up or deleting areas of concern in an ordered way.
An ENT referral (if not done already) seems essential to assess nasal emissions; the basis may contribute to unintelligibility as well as vocal fatigue. Question velo-port mechanism sufficiency and any vocal chord paresis (the latter of which may contribute to his deep voice). If you have not done so, use the Verbal Motor Production Assessment (Hayden and Square). This is a very thorough assessment that includes three main areas (Global Motor Control, Focal Oromotor Control and Sequencing), and allows you to see the hierarchical but interactive nature of speech and where to begin treatment.
His fillers are in both conversation and reading and, as such, are puzzling. Word retrieval, organizational and generative issues may contribute but do not explain. I do not think this is evidence of stuttering unless he has become an extremely covert stutterer. Many covert stutterers are missed, so take a good look at this.
Social communication skills (including confidence) may contribute to many issues. Therefore, he needs a counseling referral or a psychological work-up.
You mention ADD, but has this actually been diagnosed? This is a period of information-gathering and you may be the person to manage it.
Janet Y. Skotko is the sole proprietor of The Voice Institute in Tampa, Florida and has been an SLP for over 30 years. She is also one of the inaugural cadre of Board Recognized Fluency Specialists. Janet's areas of special interest range from stuttering and voice disorders to improving communication skills and accent reduction. She enjoys the difficult cases even outside these areas. Janet can be reached at Voice580@aol.com.
Margaret Fein is a certified SLP in private practice for over 27 years. She has special area interests in auditory processing, auditory-visual integration, and language-based reading disorders.