Diagnostic concerns in fluency

disorders
Fluency Assessment

Data Analysis &

Collectio Interpretation
n

Information &
Counseling
 Assessment Overview

Fluency Assessment
Plan for
Data Collection

Determine Goals Determine Information Select Assessment

of Evaluation Needed Tools

Interviews
Generate Consider Resources Objective
Questionnaires
Dx Questions for Information Measures
Self-Evaluations

Attitudes
Client Speech Samples:
Formal Perceptions
Family Speech &
Tests Avoidance Behavior
Teachers Nonspeech Behaviors
History
 The goals of a fluency
evaluation
 For young children:
 Do they stutter?
 Developmental stuttering vs. normal disfluency vs. language formulation
disfluency
 If they stutter, how likely is recovery? – examination of risk factors
 What is the appropriate next step?
 Monitoring, parental consultation
 Indirect management
 Direct management
 For older children and adults:
 How significant is the stuttering problem?
 In terms of overt symptoms
 In terms of associated behaviors, including frustration, fear, avoidance, and
perceptions of handicap and disability
 What factors affect fluency and associated affective and emotional states?
 What are the goals of fluency therapy?
Appraising overt symptoms: the
speech sample

 From children:
 Conversation with you and with the parents
 Narrative (e.g., “Frog” stories)
 Recreation of situations/contexts in which fluency is
reported to wax and wane
 From adults:
 Monologue (may be done during case history)
 Conversational interaction
 Reading
 Optional: appraise consistency and adaptation using
repeated reading of materials
 Tallying disfluencies (overt behaviors)
from the speech sample
 What gets counted?
 Normal disfluencies
 Stutter-like disfluencies (SLDs)
 Calculating proportions – what are your numerators and denominators?
 Appraising frequency
 Via percent stuttered words or syllables
 Problems with purely time-based measures
 Describing typology
 What are the proportional incidences of major disfluency subtypes?
 Reliability of behavioral measurements – Tom exercise
Examining accessory features

 A tip: listen to the tape without looking,

then look without listening
 Things to look for:
 Atypical speech production postures
 Ancillary body movements
 Eye gaze
 Sample assessment instruments: SSI-
3, Cooper Scales
Attitude assessment

 Potential  How does stuttering affect

the individual’s everyday
measures: behavior?
 See sample  What are perceptions of
handouts disability and handicap?
 How do they feel about
speaking and stuttering?
 What do they know or
believe about their
stuttering?
Goals of the assessment

 For parents, what are the goals? Can

they supply more than one?
 Using goals to explore options
 What are the client’s goals?
 Dx summary –
preschool children

 Questions that need to

be answered:
 Is it stuttering?
 What is the likelihood of
spontaneous recovery?
 What has been done up
to now, with what
results?
 What are the pro’s and
con’s of various
treatment models?
Preschoolers (continued)
 Information required:
 Frequency, duration and types of disfluency
 Presence of struggle or tension
 Presence of awareness and reactions to
moments of disfluency
 Assessment scales (see handouts)
 Status of other speech/language abilities
 Parent-child communicative style
 Parents’ reactions and attitudes toward behaviors
 Parents’ understanding of the nature of stuttering
 Perceived risk factors for chronicity or worsening
of symptoms
Preschoolers (continued)
 Case history specifics:
 Parents’ information about onset, course of
disfluency patterns over time
 Medical, social and developmental history
 Child and listener responses to disfluency
 Level of awareness, frustration, avoidance, self-
consciousness
 Reactions of others in the child’s environment,
including advisements
 Parents’ beliefs about cause of the problem
 Parents’ views of the child’s personality and
temperament
 Family history of stuttering and other
communicative disorders
Behavioral measures for pre-
schoolers: What are SLDs?
 Stutter-like disfluencies include:
 Sound, syllable and monosyllabic whole word
repetitions
 Weighted scores for disfluency take into account the
number of iterations
 Blocks, prolongations, broken words
 Other disfluencies might include:
 Interjections, filled pauses
 Revisions
 Multisyllabic word or phrase repetitions
 Hesitations
 Step Two: Assess predictors
of remission and chronicity

 The facts:
 ~80% of children who begin to stutter will
recover (apparently without clinical
intervention)
 The time frame for remission may be more
limited than previously supposed (Yairi, et al.,
1996; Ramig, 1993)
 Predictors of chronicity and
remission* Time
since
onset
Gender

SLD's over
12 mos.
post-onset
Age at
Family hx of onset
persistence &
recovery Speech &
language
skills
*from Yairi, Ambrose, Paden & Throneburg (1996),
JCommDis, 29, 51-77.
More
concern Weighing the odds
Family history of chronic stuttering
Male
Stable or increasing pattern of Stutter-Like
Disfluencies (SLD's) over 12 mos.
Stuttering onset after 36 months
Relatively poorer speech/language performance
No family history or history of
recovered stuttering
Female
Decrease in SLD's over 12 months
Early onset of symptoms
Less Strong speech/language skills
concern
Patterns to monitor

14

12

10

0
January April July October January April July October January

Recovery Chronic Immediate concern

“Watch and see”, not wait and see

 As in SLI, the rapid course of

remission, but uncertain future of
individual children requires the
partnership of parents and clinician to
actively monitor progress and
establish guidelines for implementing
intervention (Paul, 2000)
 Dx summary: school-aged
children
 Questions that need to be answered:
 How complex has problem become? (awareness, shame, guilt, self-image
as a CWS?)
 Is any part of problem language-based?
 What are relative contributions of physiological factors, psychological
factors, attitudes and learning?
 What is child’s perception of problem? How does it compare to the
parents’ perceptions?
 What intervention strategies would be most beneficial?
 In what capacities will parents/school be involved?
 Educational component
 Coordination of services
 School-aged children
(continued)
 Information required:
 Medical, developmental, social and educational history
 Full understanding of speech/language abilities
 Frequency, duration, concomitant behaviors
 Impact on emotional development
 Parental/family/school reactions and attitudes toward
stuttering
 Child and parents’ understanding of the nature of
stuttering
 Previous speech therapy: approaches and outcomes
 Listener reactions and responses to listener reactions
 The CALMS Model of Stuttering
(Healey, et al., 2001)

Affective - feelings, emotions, attitudes

Cognitive Linguistic
- thoughts - language
- perceptions skills, lang.
- awareness formulation
- understanding demands &
discourse

Social - effects of Motor - Sensori-motor

type of listener & sp. situation control of speech movements
 An Example of How the CALMS
Factors
Interact During a Speaking Situation
Affective - I feel embarrassed, I’m confused,
I’m afraid, I hate my stuttering.

Linguistic
Cognitive - What am I going
- I hope I don’t stutter. to say? How will
- I’m not a good talker. I say this and
- I want to avoid talking be fluent?
- People will laugh at me.

Social - I really don’t want to talk with Motor- I wonder if my

this person. I feel pressure to talk in this fluency targets will work? My
situation. tongue and voice feel tense.
School-aged children
(continued)
 Parent interview: similar to that of preschoolers;
adjust to be age-appropriate
 Teacher interview
 General questions about achievement and social
development
 How does stuttering affect these areas?
 Reactions of students and staff to stuttering?
 Child’s reaction?
 Level of participation, verbally and nonverbally in
classroom and other school activities
 Information about services received at school
 School-aged children
(continued)
 Child interview
 Move slowly until you assess how direct or open the child would
like the interview to be
 Child’s perception of the problem – what does he call it?
 Child’s perception of parents’ perception of the problem
 Child’s description of the problem
 How much does stuttering bother the child?
 What does the child do to cope with or escape from the moment
of stuttering?
 Experiences with peers: teasing, support?
 Assessment scales (see handouts, e.g. CALMS model)
 Attitude scales: CAT (DeNil & Brutten)
Tips for interviewing young
children

 Some basics:
 Don’t be alarmed if child says, “I don’t
know” or shrugs shoulders. Children are
not used to evaluating feelings. They don’t
necessarily evade. Some children just
accept things the way they are.
 Share something about yourself, and the
type of work you do:
 “One of my jobs is to help kids talk better”
 Talking to young children
(continued)
 Use analogies and examples to help the child feel
comfortable talking about problems.
 For example, “One of my friends who comes to play with me is Josh.
He sometimes gets stuck when the teacher asks him to read to the
class. Does that ever happen to you?”
 Use a marble maze with some marbles too large to flow freely. Have
some get stuck. Then say, “This marble is s-s-s-stuck. That picture
on the wall was made by Josh. It shows how he crunches up his
face when he gets stuck. What kinds of things do you do?”
Some questions to ask young
children

 Whom do you like to talk to? (At home, at school)

 Who talks the most/least (At home, at school)
 Who interrupts? Who do you interrupt?
 Who are good talkers?
 When do you want to talk well?
 Are there times you want to talk extra well?
 Do other people feel this way as well?
 When do you want to talk more than you do?
 Who listens/pays attention?
 What do you like listeners to do when you talk to
them?
Qualifying children for services
in the schools
 Please see diagnostic considerations
for qualifying CWS under IDEA and
writing IEPs (separate handout).
 Dx summary - Adults
 Questions you need to answer:
 What type of fluency disorder is it?
 Developmental stuttering
 Cluttering
 Neurogenic stuttering
 Psychogenic stuttering
 If developmental stuttering, what are the relative
contributions of physiological, psychological, attitudinal
factors and learning?
 Why does the client seek tx now? – goals?
 How does disfluency affect client’s communication and life?
 What intervention strategies will be most appropriate?
 Adults (continued)
 What information will be needed?
 Disfluency types
 Severity of the disorder
 Percentage of disfluencies
 Concomitant behaviors
 Fears and avoidances
 Client’s attitude toward disorder
 Core and secondary behaviors
 Emotional reactions/attitudes
 Social, vocational and lifestyle information
 Adults (continued)
 Interview specifics:
 Onset and early development; how was stuttering handled in
family? What does client believe caused it?
 Impact educationally, socially and vocationally
 Outlook: hope for change, past tx experiences, motivation to
change
 Patterns of recovery and relapse, situational variability
 Family history
 Level of fear of speaking and stuttering
 Avoidance patterns
 Self-perceptions
Adults (continued)

 Measuring impairment, disability and

handicap (Yaruss & Quesal)
 Speaker’s reaction to stuttering
 Functional communication
 Quality of life
Measuring speaker reactions:
tools

 Watson (1998) Inventory of

communication attitudes
 Ornstein & Manning (1985) Self-
Efficacy Scale (SEA-Scale) for Adults
who Stutter
 Andrews & Cutler (1974) – adaptation
of Erickson’s S-Scale
 Yaruss & Quesal (2000)
Diagnostic interpretation
 For children
 Provide data on prognostic indicators, and work
with parents to determine next steps, which
should include a minimum of active monitoring
and counseling to palliate symptoms.
 Introduce information about therapy approaches
 Provide information and information sources to
help family explore stuttering.
 For adults:
 Explain the therapy approaches that you
offer, and explore acceptability to client.
Is this what the client had in mind?
 Negotiate the “terms” of therapy
 Help them become informed consumers;
provide information sources.