Working with

Challenging
Situations
Kim Caron, Shandra Lock, and Annie Loof

Working with Challenging Situations

Challenging behaviors in the schools
Malingering
Stuttering
Memory

Challenging Behaviors
97% of elementary school children with identified behavior disorders
scored 1 to 2 standard deviations below the mean on 1 or more subtests of
the Test of Language Development-Intermediate.
The prevalence of challenging behaviors in preschool children with
language disabilities has been reported to be as high as 59%.
Children with language disabilities spent 42% of their time engaged in
behaviors grouped under withdrawal as opposed to the 17% that typically
developing children spent.
(Nungesser & Watkins, 2005)

Challenging Behaviors
Commonly identified challenging behaviors include:
Aggressiveness
Manipulative behaviors
Emotional disturbances
Disruptive/deviant behaviors
Antisocial tendencies or isolating behaviors

Manipulative Behaviors
Manipulation refers to behavior that covertly elicits desired responses from
others and implies an element of inauthenticity or deceit (Feltham &
Dryden, 2005).
SLPs tend to think of themselves as not easily manipulated.
When manipulated, SLPs often blame the client.
Underlying motive to manipulate: to gain control and self-esteem in a
challenging situation
(Flasher and Fogle, p. 403)

Think of a time when you were manipulated or in a challenging

situation with a client...
What did your client do?
How did you feel?
How did it impact your session?
It is important to understand the clients rationale and motivation
behind his/her behaviors instead of ignoring them.

Handling Challenging Behaviors

Intervention strategies utilized by classroom teachers:
Time outs: 64%
Redirection: 33%
Warnings: 18%
Punishment: 16%
Modeling how to use words: 11%
Changing classroom environments: 9%
Increasing problem-solving skills: 4%

Handling Challenging Behaviors

Promote Awareness and Education
Think about behavioral functions
Functional assessments
Communicative competence
Socially appropriate skills

Take an active role in the classroom

Teach emotional language
Use peers
Get parents involved

(Nungesser & Watkins 2005)

Discussion
Think back to that challenging behavior
Would you change the way you reacted? What could you have
done differently?
Are there any additional ideas that you have for handling
challenging or manipulative behaviors?

Malingering
Malingering involves intentional simulation of an illness or disorder with a
conscious motivation of external incentives or gains, such as financial compensation
from insurance, or avoiding expectation of others, such as returning to gainful
employment (Johnson & Jacobson, 2006).
Malingering is recognized as the intentional production of false or grossly
exaggerated symptoms motivated by external gain (American Medical News).
Malingering is the intentional feining or exaggeration of disorders for the purpose
of secondary gain such as obtaining an insurance settlement, getting disability
payments, or avoiding criminal prosecution.

Why People Malinger

Food
Shelter (especially in the winter)
Narcotic medications
Financial gain
Avoidance of jail, work, military,
or family responsibilities
Transfer to psychiatric hospital
to avoid arrest

(Adetunji et al., 2006)

Types of Malingering
Pure malingering is when all of an individuals symptoms are falsified.
Partial malingering is when existing symptoms are exaggerated.
Another form of malingering occurs when someone denies existing
problems or symptoms.

(Seery, 2005)

How to Identify a Malingerer

Obtain past records

Check for consistencies
Use tests and questionnaires
Focus on facts
Check past compliance
Look at social history

Malingering
In 2005, ASHA published a position statement indicating that SLPs have a
role in the assessment and management of individuals with
communication disorders associated with cognitive impairment, making
malingered neurocognitive disorders a concern for SLPs.
Stuttering
Memory

Malingering
and Stuttering
Despite the variable
nature of stuttering, the
existence of some
predictable patterns of
occurrence and remission
can aid the detection of
malingering (Seery,
2005, p. 284).

Case Study
Defendant: white male in his late 30s accused of armed robbery

Lady give me the money, or Ill shoot.

Reported that he stuttered since childhood and no familial history of stuttering

Fluency assessment protocol

Spontaneous speech sample

Choral reading
Imitation of words, phrases and sentences
Whispered, shouted, and lipped speech tasks
Automatic speech tasks

Fluency Assessment Protocol Results

Spontaneous speech: severely disfluent (104 disfluencies per 100
words).
Sound and syllable repetitions (up to 10 extra units in length)
Sch-sch-sch-sch-sch-sch-sch-sch-sch-sch-school

There were no consecutive utterances free of stuttering (8/140 were

perceptually fluent - single word responses)
No secondary nonverbal behaviors were exhibited and direct eye was made

Choral reading, imitation of words, phrases, and sentences, whisper and

shout tasks, and automatic speech: severely disfluent

Differential Diagnosis of Malingering

Although evidence supported an authentic case of developmental
stuttering, other results suggested partial malingering in the form of
exaggeration of stuttering and accompanying symptoms.
Well this umuh umuh umuh umuh umuh umuh u- uuuumuh uuumuh
uuumuh uuumuh uuum uuum kid that its a its a big long thi-thingthing.
High level of stuttering severity (39%)
Locations and pattern of stuttering
Lack of improvement in any known fluency-inducing conditions
(e.g. unison, lipped speech, tapping, prolonged speech)
Relaxed and direct eye contact

Malingering and Memory

Rey Test - developed by Andre Rey in 1964
Also known as the Memory for Fifteen Items Test
Measures immediate span of short-term memory
Validate memory problems
Detect malingering

15 characters and shapes in 5 rows with 3 items to a row

10 seconds to memorize
Patient is asked to recall picture
(Martin, 2002)

Rey Analysis
Patient has to remember 5 rows of chunked information
Two scores are determined
Total number of items recalled regardless of order
Number of correctly ordered rows

Expected errors: perseverations and reversals

9-point cutoff

< 9: suspected malingerer

Case Study

39-year-old woman
Reported experiencing taking a puck to the head during her sons
hockey game
Complaining of memory problems that interfere with her supervisory
duties at a local university
I cant remember names of my students that Ive known for years.
I dont think Im performing as well as I have been! I think I need some
time off.

Case Example

Would you suspect this client is malingering or has a cognitive

impairment?

Malingering
Malingerers would be suspected to perform more poorly than
cognitively-impaired patients.
Floor Effect

Individuals attempting to malinger will fail at a task which even grossly

impaired individuals are likely to perform adequately.

(Martin, 2002)

What should you do if you

suspect your client is
malingering?

What ASHA tells us

In addition, when provision of treatment that includes all of these factors is
beyond the expertise of an individual clinician or the clinician's
recommendations are not acceptable to the individual, referral to
professionals with specific expertise in the area of concern should be
made prior to discharge.
Reason for Discharge:
The individual demonstrates behavior that interferes with improvement or
participation in treatment (e.g., noncompliance, malingering), providing
that efforts to address the interfering behavior have been unsuccessful.

References
Adetunji B., Basil B., Mathews M., Williams A., Osinowo T., & Oladinni O. (2006) Detection and Management of Malingering in a Clinical Setting
Primary Psychiatry, 13(1):61-69.
American Speech-Language-Hearing Association. (2004). Admission/discharge criteria in speech-language pathology [Guidelines]. Available from
www.asha.org/policy.
Flasher, L. V., & Fogle, P. T. (2012). Counseling skills for speech-language pathologists and audiologists. Clifton Park, NY: Delmar, Cengage Learning.
Martin, J. A., (2002). Qualitative scoring of the Rey 15-Item Memory Test in a forensic population. Louisiana State University: Department of
Psychology. Accessed on April 7th, 2016.

Nungesser, N. R., & Watkins, R. V. (2005). Preschool teachers' perceptions and reactions to challenging classroom behavior. Language
Speech and Hearing Services in Schools, 36(2), 139. doi:10.1044/0161-1461(2005/013)
Seery, C. H. (2005). Differential diagnosis of stuttering for forensic purposes. American Journal of Speech-Language Pathology, 14(4),
284-297. doi:10.1044/1058-0360(2005/028)