assessment of fluency disorders. / kunnampallil gejo john

7/27/2019 Assessment of fluency disorders. / KUNNAMPALLIL GEJO JOHN

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10/23/2013 KUNNAMPALLIL GEJO JOHN 1

Assessment of fluency disorders

KUNNAMPALLIL GEJO JOHN,MASLP


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KUNNAMPALLIL GEJO JOHN 210/23/2013

INDEX:

Introduction

Reasons for evaluating fluency

Goals of assessment

Assessing Fluency disorders in Children

Assessing Fluency disorders in adults


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INTRODUCTION:

Fluency speakers effortless flow of speech.

Variables that determines the fluency - the temporal

aspects of speech production.

Pauses, rhythms, intonation, stress and rate are controlled

by when and how fast we move our speech structures.

- Starkweather (1980,1987)


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In his description of fluency, Starkweather also includesthe effort with which a speaker speaks.

By effort, he means both mental and physical work aspeaker must do to speak.

FLUENT SPEECH is continuous and the continuity of

speech can be disrupted by hesitations of sound,syllables, words and phrases, prolongation of speech etc.


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Rate of speech, defined as the number of syllablesuttered per unit of time, is another aspect of fluency.

However rate should be interpreted as a complementaryfactor in determining the fluency and therefore

stuttering.


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Stuttering is most frequently seen fluency disorder

The term stuttering means:

1. a) Disruption in the fluency of verbal expression, which is(b)characterized by involuntary, audible or silent repetitions orprolongations in the utterance of short speech elements namely;sounds, syllables, and words of one syllable.

These disruption (c) usually occur frequently or are marked in character

and (d) are not readily controllable.

2. Some times the disruptions are (e) accompanied by accessoryactivities involving the speech apparatus, related or unrelated bodystructures or stereotyped speech utterances.

3. Also there are not infrequently are (f) indications or report of thepresence of an emotional state ranging from a general condition ofexcitement or tension to more specific emotions of a negative naturesuch as fear, embarrassment, irritation or the like.

- Wingate (1964)


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CLUTTERING is another fluency disorder in whichspeech fluency involves both the rate and rhythm ofspeech and resulting in impaired speech intelligibility.

Speech is erratic and dysrhythmic consisting of rapid andjerky spurts that produces gasps of words unrelated togrammatical structures of the sentence.


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REASONS FOR THE EVALUATING SPEECH FLUENCY

To determine whether the client has a fluency disorderor is at risk of developing one.

To determine the type of fluency disorder

To identify the set of behaviors that defines the clientsfluency (stuttering) problems.

To assess progress

To assess the severity of the problem for findingeligibility, litigation and other purposes.


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GOALS OF THE ASSESSMENT

To determine whether the problem exists that wouldrequire treatment, sometimes the severity of theproblem and the prognosis regarding treatment cannot bedetermine from an initial assessment

- Conture, 1997; Guitar, 1998.


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KUNNAMPALLIL GEJO JOHN10

10/23/2013

InitialContact

Case history

form

ParentInterview

Preliminaryassessment

Articulation Voice Oral Peripheral Language

Hearing Speech samples

Fluency

Primary behaviorsMultiple part word repetitions,

Prolongations, Pitch or loudness rise,

Hard onsets, Silent blocks, Distortions,Struggle and tension

Secondary behaviors

Loss of eye contact, eye closures or

blinking, audible inhalations, head orbody movements.


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KUNNAMPALLIL GEJO JOHN11

10/23/2013

Differential diagnosis is an important element of fluencyassessment

- Ambrose & Yairi, 1999; Onslow & Packman, 2001.

Which oneis it?

Cluttering?Developmental Stuttering?

NeurogenicStuttering? Stuttering like

Dysfluencies?


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SOME CONSIDERATION

Before getting into the assessment, a few things to be

keep in mind when seeing a new client

Every client is different

Consider the person as well as the problem

Diagnosis is an ongoing process


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ASSESSING FLUENCY DISORDERS IN CHILDREN

First step in designing an appropriate program of

management - Evaluation of the characteristics of afluency disorder and the effect that disorder has on apatients ability to communicate

The evaluation process involves the gathering ofpertinent information (case history) from collecting dataon the patients performance of various tasks from thepatient and also from the care takers, as well as.

The speech pathologist to diagnose the fluency disorder,determine the relative efficacy of various treatment

approaches and formulate a prognosis.


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What to evaluate?

The evaluation should address two basic aspects:

(a) The stuttering (moments and variability) and

(b) The concerned (the child, the parents, etc).


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1. Evaluation and description of the dysfluency of thechild:

Description should be in terms of the type ofdisruptions/blocks, frequency, duration, severity and theassociated non speech behaviors.

Types of disruptions/blocks:

Look for core behaviors (Van Riper, 1982): repetitions,prolongations and blocks.

Other types of blocks like interjections, revisions, andpauses may also be observed.


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Frequency and duration of blocks:

Children who stutter differ from each other on the

frequency and duration.

Usually stuttering frequency is greater than 5% and theaverage duration of a block may be around a second.

Higher the frequency and longer the duration, the moresevere the stuttering,

Secondary behaviors:

The associated non-speech behaviors may look like overtreactions that a child has acquired/learnt torelease/prevent the core behavior.


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2. Evaluation and description of the speech and language productionin general:

Language performance

Mean length of utterance

Rate of speech during instances of stuttering and fluentproductions

Voice aspects during stuttering instances

Articulatory proficiency

Oral peripheral mechanism

Prosody

Intelligibility of speech


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Stuttering seems to have close links with speech language processing and production

- Bloodstein, 2002

Children who stutter follow the same linguistic pattern asthat of adults who stutter more on pronouns andconjunctions than nouns, verbs, adjectives and adverbs.

In children the loci is identified as the beginning ofsyntactic units (sentences, clauses and phrases) and notas words initial positions.

A difficulty in linguistic planning and preparation

- Bernstein Ratner, 1997


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Conture (2001) - Phoneme selection component oflinguistic planning in children who stutter.

Associations with phonological skill, / speech productionrate and speech motor systems skill / potential to

execute fluent speech.

Nearly 24 45 % of children who stutter exhibit somedegree of articulation / phonological difficulties

- Louko, Conture& Edwards, 1999

So evaluation should include aspects of language,phonology and other speech dimensions.


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3. Describe the developmental history ( speech andlanguage )

Speech and language development history is importantfor us to make decisions of the capacity of the systemto cope up with the processing load during speech andlanguage acquisition.

The contention that stuttering occurs while the childslanguage acquisition proceeds rapidly than his developingmotor system or is delayed causing frustration and

difficulty in speaking, can be ascertained by nothingdevelopmental history .


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4. Track the pedigree

Stuttering tends to run in families and is more common in malesthan females

- Kidd , 1984 ; Ambrose , Cox & Yairi , 1997 ; Felsenfeld, 1997

However, the exact percentage of occurrence in families andgender ratio is still not clear.

These genetic studies assert biological predisposition towardschildren who are more likely to stutter.

Keeping aside the complex ( confusing for a clinician) conclusionsfrom the genetic studies , the clinician should expect that if there

was a family history of stuttering , there is more likely a chance toimpose a strong negative feeling about the disorder on the child .

Such feelings need to be explored and discussed during theinterview. This is important both in assessment and treatment.


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5. Evaluate the temperament and emotional stability ofthe child

Most children these days have very low emotionaltolerance and they are often hypersensitive.

This might be due to results of over protection andexpectations on the child childs performance in anyactivity of interest to the parents.

Guitar (2006) also suggests that understanding thetemperament of the child.


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Increased physical tension during stuttering instancesmight be expected of a child due to his reactivetemperament, and may lead to chronic stuttering.

A child with placid temperament may be more relaxedand will probably ignore / accept stuttering, therebymay outgrow / cope with the problem more easily.


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6. Evaluate the three As of the concerned: awareness,

anxiety and attitude towards stuttering.

Awareness of the problem , anxiety that arises before ,during and after stuttering spells and the attitude thatone develops will reflect on the childs and the patientsemotional reactions towards stuttering .

These emotional reactions may range from fear , guiltand embarrassment to complete helplessness anddepression.

These negative feelings need to be combated andanalysis of the As will facilitated the unlearning of thefear based stuttering behaviors in the child.


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When to evaluate?

Evaluate as soon as the concern arises.

The concern may be raised by the parents, family andfriends, school and the child him / her self.

The typical age at which the onset of stuttering isrepeated is between two and four

- Conture, 2001

70% of children with developmental stuttering have agradual onset and nearly 50 75% improve without anyformal treatment

Guitar 2006


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Guitar also summarized the factors to be associatedwith the chances for natural recovery from stuttering,and they include the following:

1. Good language and phonological skills

2. Good motor ( non verbal ) skills

3. No family history of stuttering and naturalrecovery from it in the family members.

4. Early age of onset and

5. Being a female.


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Evaluation closer to the age at which the concerns arise isessential so that either intervention can be started or

the parents can be asserted regarding spontaneousrecovery.


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How and Where to evaluate?

For both clinical as well as research purpose, often timeswe would require to make categorical judgmentsregarding stuttering and fluent speech.

To arrive at this decision one necessarily need to conductan interview and also observe the child, the concernedand their interactions and behaviors.


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Assessment using standardized tests like stuttering

severity instruments (Riley) may be done.

Comparison with norm references may seem useful inoccasions to diagnose, differentially diagnose and arriveat the degrees of severity of the problem.


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Case History Form:

Informs the clinician about:

The parents perception about the problem, at present

Its onset and development, and

The childs medical and family history and school history.

The first opportunity for the clinician to show her understandingabout both the general nature of stuttering and the impact it canhave on the child and his family.


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The first chance for her to:

begin making the problems less mysterious,

to respond to some of the myths or misinformation that thefamily may associate with the problem;

to alleviate the feelings of guilt that usually accompany

stuttering, and

to begin to provide an overview about the direction of treatment.

The clinicians ability to orientate the family to the true nature ofthe problem may be the main benefit that the child and the familyreceive from the diagnostic meeting(s).

- Contour (1997)


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Parent Participation in Assessment:

The motivation for initiating treatment may be minimal if the familyphysician or friends and family members suggest that the problemwill likely go away by itself

- Ramig, 1993c

The most important aspect of the interview process is the cliniciansstyle and ability to be flexible and creative as she interacts with theparents.

- Rustin & Cook (1995)

Talking more freely about stuttering directly with preschoolers, aswell as with their parents may reduce parents distress about theirchilds stuttering; perhaps talking about stuttering openly reduceseveryones fear on it.


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During parent interview, the clinician gives them anopportunity to talk about the matters that they feel andalso the matter that they would like to share in

confidence.

Clinician begin interview by letting parents know what he

is going to do with them and their child during theremainder of the evaluation.

Clinician should assure them that, there will be a time forsharing the assessment information and recommendationwith them at the end.


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Usually during the assessment the clinician used to asks

open-ended questions.

When parents have had a chance to describe the problemand appear to have no more to say at that moment,clinician should ask about the first stages of the childslife (the childs birth and development) and then work up

toward the present time.


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In the ensuing conversation, the clinician should be sure that he/shegets information indicated by the questions which is mentionedbelow.

1) Were there any problems during pregnancy or the birth of the child?

2) What was the childs speech and language development like? How didit compare with siblings development and with your expectations?

3) Describe the childs motor development compared with that of hisbrothers, sisters or other children?

4) Have any other members of their family had speech and language

disorders?

5) When was the Childs disfluency first noticed?


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6) Was anything special going on in the childs life whenstuttering started?

7) What was the disfluency like when it was first noticed?

8) What changes, if any, have been observed in the childs

speech since stuttering was first noticed?

9) Does the child appear to be aware of his dysfluency?

10) Does the child sometimes appear to change a wordbecause he expect to be disfluent on it?


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11) Does the child seem to avoid talking in some situations,when he expects to be disfluent?

12) What do the parents believe caused the problem?

13) How do the parents feel about the childs disfluencyproblem?

14) What, if anything have the parents done about thedisfluency problem?

15) Has the child been seen anywhere else for the problem?If so, what were the outcomes?


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16) When and in which situations does the child exhibit themost disfluency? The least disfluency?

17) How does the child get along with his brothers andsisters and other children?

18) What is the childs personality and temperament like?

19) Is there anything else you can think of to tell us thatwill help us better understand your childs stuttering?


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Child Interview

Following questions can be ask during child interview.

1) Does the child think that he has any trouble talking?

2)How does the child describe the problem? When does ithappen? What is it like at different times?

3) Does he use any helpers or tricks to get words out?

Does he avoid certain words?

4) Are certain speaking situations more difficult? Does heavoid them?


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5) Does anyone ever tease the child about his speech?Who? How does he feel about it? How does he react?

6) How does the child feel about his speech?

7) How do the childs parents feel about his speech? Whatdo they do when he stutters?

8) Ask the child, can you think anything else important forme to know about you or about the trouble you sometimeshave when you talk?

P RENT CHILD INTER CTION


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PARENT-CHILD INTERACTION

Clinician should observe one or both parents interacting with theirchild.

It is better to do this at the beginning of the evaluation for severalreasons.

1. Parents may be less affected by clinicians orientation towardstuttering and may thereby give the clinician more naturalsample.

1. This interaction gives clinician a chance to see the childs

stuttering first-hand.

1. Clinician can observe the way in which the parents interact withtheir child.


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The parent-child interaction can be done formally orinformally.

Some clinician observe the interaction in the waiting roomand make only mental notes

Some may visit the childs home

Some uses videotape recording of the parents and thechild in the play style interaction in a treatment roomsupplied with toys and games.


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CLINICIAN-CHILD INTERACTION

Here, the clinician can see directly what the childsdisfluency is like, how he responds to various cues and towhat extent the childs disfluency is modifiable.

Always better to tape-record this interaction for lateranalysis.

If videotape is available, it is preferable, since visualcues are sometimes critical in determining a childsdevelopmental/treatment level.


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Clinician focuses their interaction on toys or gamessuitable to the childs age.

Clinician should talk in an easy, relaxed manner much likethey advice parents to do.

If the child is stuttering similarly to the way the parentshave described, clinician keeps the same speech stylethroughout the interaction.


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However, if the child is entirely fluent or normallydisfluent and the parents have described behaviors which

a clinician feels are stuttering, clinician speeds up thespeech rate and ask many questions.

Occasionally, clinician interrupt at some point to elicit thedisfluent speech, which is perhaps more characteristic.

They do this to avoid misdiagnosing a child who isstuttering as a normally fluent speaker.

T lki b t St tt i


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Talking about Stuttering:

Prior to the clinician-child interaction, clinician try to

determine if the child is aware of his stuttering.

If the clinician thinks he isnt, then use only theirobservation in non-directive play to assess his speech.

If it is pretty clear, from earlier information or fromclinicians own observation, that client is aware, then tryto determine how able the child is to talk about his

stuttering.


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This gives clinician an opening to go further and discusshis stuttering with the child.

Some clinicians will help a child talks about his stutteringby first telling the child about another child who stutters

- Bloodstein, personal communication, 1990

In discussing stuttering with a child, clinician usually tryto use their vocabulary such as getting stuck or havingtrouble on words.


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In summary, the goals of these attempts to discuss thechilds disfluencies with him are:

1. To see if the child is accepting of himself and hisdisfluencies enough to discuss them.

2. To indicate to the child that he is not alone withthe problem and moreover we may be able to helpthem.

A Child Who Wont Talk


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A Child Who Won t Talk

A very shy child may start to cry and along to his parents.

In this situation, clinician talk with the parents in one partof the room while another clinician plays with the child in

another part.

Clinician talk few minutes about general things, letting thechild become familiar with the clinician with whom hes

interacting.

Then clinician may suggest to the parents that we and theymove into an adjacent room but keep the door open.

With this arrangement clinician can usually talk about


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With this arrangement, clinician can usually talk aboutsensitive matters without being overheard.

At times, certain children will separate from theirparent, but wont interact with clinician during evaluation.

Then avoid asking direct questions. Instead play with thechild.

After several minutes, clinician usually find that the childrelaxes and begin to speak spontaneously.

After this clinician can begin more direct interactions.

Only after the child gets quite comfortable, clinicianattempt to discuss his trouble talking.

A Child who is entirely Fluent


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A Child who is entirely Fluent

Some children may be entirely fluent during the

evaluation.

In these cases, there are several options.

1. The tape recording, that the parent sent theclinician, may have a good enough sample ofstuttering to use it for speech sample.

1. If the child is use a particularly fluent episode,clinician may reschedule him for evaluation at alater time.


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SPEECH SAMPLE

Usually, more than one speech sample i.e. a tape recordingthe parents have sent in, the parent-child interaction andthe clinician child interaction.

Clinician choose the sample that has the greatest amountof stuttering for the most detailed analysis, but also note

the extent of stuttering/fluency on the other samples.

Assessing types frequency and duration of dysfluency:


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Assessing types, frequency and duration of dysfluency:

Different types of dysfluencies can be identified as per

Bloodsteins 1987 criteria:

Repetitions:

1. Syllable repetitions - ma ma mattu

2. Part word repetitions od od odthayidha

3. Whole word repetitions obba obba

4. Phrase repetitions

Pauses:


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Pauses:

Unfilled pauses silence longer than 300ms

Filled pauses pauses with extraneous sounds such as /a/,/m/ etc.

Prolongations: aaaaaaaaa aagaa

Interjections: this well etc.

Frequency of stuttering:


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Frequency of stuttering:

Reported in %

No: of stuttered words/utterances in the analysed sample.

Sound and syllable repetitions within amultisyllabic word counted as iterations of a single repetition.

e.g. /pe pe pe pen/ - one repetition and three iterations.

Percent dysfluency = total no: of dysfluencies/total no: ofwords * 100

Duration:


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Duration:

Longer stutterings are worser than shorter ones.

An avg of the duration of the 3 longest blocks is a fairrepresentation of the duration of the block.


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TO DETERMINE WHETHER OR NOT THE CHILD ISSTUTTERING

Eliciting Fluency Breaks:

During the assessment of the children, there will be

occasions when the very behaviors, the clinician wants toobserve and evaluate are not present.

On such occasions the clinician may choose to elicit thesebehaviors.


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Essentially what clinician are doing is creating a speakingsituation where temporarily, the demands we are placing

on the child exceed his ability to use his speechproduction system.

For e.g. turn away as the child is describing an event oractivity. Loss of listeners attention has long been knownas a powerful technique for eliciting fluency breaks inchildren

- Johnson, 1962, Van Riper, 1982

The clinician may ask the child to respond quickly to a


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The clinician may ask the child to respond quickly to aseries of questions or ask him to answer somewhatabstract or difficult to answer queries

- Guitar & Peters, 1980

Depending on the age of the child he or she could beasked to read from books that are somewhat above his

grade level (Blood & Hood, 1978)

Or

Asked to describe a series of pictures which arepresented at a rapid rate so that he is unable toformulate a complete response.

It is not necessary to elicit many of these breaks


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It is not necessary to elicit many of these breaks.

Once a few examples have been obtained, the cliniciancan consult with the parents to determine it thesebehavior they have observed and are concerned about.

Support for the importance of observing children in avariety of speaking situations was noted by Yaruss(1997a) in a study of 45 pre-school children undergoing

diagnostic evaluation for stuttering.

Frequency counts were obtained for both more and less


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Frequency counts were obtained for both more and lessusual disfluency types for each of the children as theytook part in 3 to 5 of the following situation.

Parent child interactions

Play

Play with pressures imposed

Story retell

Picture description

Results:


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Results

These children who stuttered showed significantly more

variability across the speaking situation than within anysingle situation.

Children who produced a higher overall frequency of lesstypical disfluencies also exhibited greater variability.

No significant correlation was found for the more typicalfluency breaks.

Finally, the play with pressure situation resulted in thegreatest number of disfluencies, although this was notthe case for all the participants, as many childrenexhibited highly individualized patterns.


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Based on these results, Yaruss (1997a) suggested thatsampling of a childs fluency in a single speaking situationis unlikely to result in a representative sample of

behavior, particularly for children who exhibit a greaternumber of stuttering like disfluencies.

The Nature of the Fluency Breaks


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Yairi (1997) recommends a speech sample of at least 500 syllables.

The following guidelines are based on a per-100-syllable disfluencymetric.

Behavior Preschool children who stutter

1. Total number of disfluenciesper 100 syllables Average of 16

2. No. of SLD per 100 syllables Minimum of 3; mean of 11

3. Percent SLD to totaldisfluencies Range of 60% to 75%

4. No. or SER per 100 syllables Mean of 6 to 8

Behavior Preschool children who stutter


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5. No. of units per instances of SER Mean of 1.5

6. Percent of SER containing two or more extra units. Mean of 33%

7. No. of SER containing two or more extra units per 100syllables

Mean of 3

8. Percent of disfluencies occurring in clusters Mean of 50%

9. No. of disfluencies per cluster Mean of 3

10. No. of face and head movements per disfluency Mean of 1.5 to 3

11. Duration of disfluencies in msec Mean of 750

12. Duration of interval between repetition units Mean of 200 msec

13. Proportion of silent interval to total duration of SERcontaining one extra unit

Mean of to 1/3

Conture (1997) also suggests that clinicians consider a


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( ) ggnumber of subtle signs that may help to distinguish thepossibility of stuttering.

1. Within-word disfluencies that average 3 or moreper 100 words (minimum of 300 word sample)

2. Sound prolongations in 25% or more of the

childrens No. of fluency breaks.

3. An average differences of two or more syllablesper second in speaking rates of the mother and

children during conversational speech, increases inthe occurrence of simultaneous-talk by the childand parent, and greater amounts of parent-childinterrupting behaviors.

4. The presence of stuttering, stuttering clusters in


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4. The presence of stuttering, stuttering clusters inthe childs two element speech disfluencyclusters.

5. Eye ball movements to the side, eye blink duringstuttering or both.

6. Clusters of two or more within-word breaks onadjacent sounds, syllables or words within anutterance.

DETERMINING A CHILDS LEVEL OF ANXIETY ABOUT


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SPEAKING

Two types of anxiety have been identified and have beenthe focus of research.

1. Trial anxiety has to do with the personsgeneral level ofanxiety

Obtained by having the client respond to self-reportscales containing questions about how he or she generallyfeel.

2. Measures of state anxiety are intended to indicate ameasure of a persons anxiety response at a specificmoment as he or she react to specific situational stimuli.


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A frequently used measure of anxiety is the state-traitanxiety inventory for children (STAIC)

Developed by Spielberger, Edwards, Montuori, Luschene,and Platzek (1972).

Score on both State & Triat sub-scale range from 20 to60, with high score representing greater anxiety.


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Using the STAIC, Craig & Hancock (1996) found nosignificant differences between 96 untreated children

who stuttered and 104 children who did not stutter (agerange 9-14 years).

In addition, the authors found no significant associationbetween stuttering frequency and state anxiety.

Determining the Likelihood of Chronicity


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g y

Assuming that the young childs fluency breaks are

considered to be unusual or abnormal, the next clinicaldecision is whether this pattern is likely to continuedeveloping.

However, the seventy of the overt stuttering does not

always predict whether or not the child will recover.

Nonverbal 8 years of struggle in the term of eye, heador general body movements may also indicate the need

for intervention.

However, if these signs are less evident, the best clinicalchoice is questionable.


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A family history of stuttering and the parents concernedresponse to the childs disrupted fluency may suggest

intervention as the clear choice.

Parental judgement of a childs speech difficulty should

be considered a fundamental part of a diagnosis ofstuttering

- Conture & Caruso, 1987, Onslow 1992,Riley & Riley 1983

On the other hand, if there is no family history of


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, y ystuttering and parents and other caregivers areunconcerned about the childs speech

To monitor the child for approximately 3 months

Yairi, Ambrose & Niermann (1983) suggest that there is atendency for children to recover within 3 months

following onset.

Stuttering Severity Index (SSI)


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g y ( )

Standard sample of the childs speech is require to

analyze with Rileys SSI.

Riley suggest that any child below third grade should be

asked to describe a set of pictures to provide a sample of150 words for analysis.

The child may also be engaged in conversation, and if thissample shows more stuttering than the picturedescription, it should be used for the analysis.


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Clinician typically use a 5 minute sample, rather than a150 word sample, because it is easier to ensure that we

have a complete sample.

Frequency of stuttering, mean duration of the three

longest stutterings and physical concomitants are scoredand the total is computed.

The total score permits a labeling ranging from very mildto very severe.

Speech Rate


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p

Clinicians assess the rate of childrens speech using the

speech sample obtained for the SSI.

Speech rates for three age groups of non-stutteringpreschoolers have been obtained by Rebekah Pindzola,

Melissa Jenkins & Kari (1989).

Children in their study were asked a series of questionsfrom the Developmental Learning Materials Picture Cards

and rates were obtained in syllable per minute (SPM) only.

Their sample consisted of 6 males and 4 females in eachof 3 age groups.

They found:


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y

for 3 year olds - 116-163 SPM

for 4 year olds - 117-183 SPM

for 5 year old - 109-183 SPM.

Differences between age group were not statisticallysignificant, and no comparisons between males andfemales were made.

Data on words per minute are not available.

Diagnosis/differential diagnosis:


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2% dysfluency or 5% dysfluency cut off criteria fordifferential diagnosis.

A child having more than 2% or 5% dysfluency is diagnosedto have stuttering.

Whatt nexttttt?!?!?!??


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Whatt nexttttt?!?!?!??Create a profile based on the observations and assessment.

Decisions

Child naturallyrecovering from the

difficulty

Needingintervention

Normal non fluency Different levels of stuttering

Diagnostic labels ascertain our decisions and to


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facilitate understanding of the nature of the childsproblem.

Earlier, labels more descriptive of the severity

based on norms

Current trend based on the behavioral profileindicates the developmental levels of

stuttering

Conclusions:


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Assessment of stuttering involves:

Judgements of the listeners in making decisions about thetype frequency duration and associated manifestations othe disorder.

Never attempt to remediate children with stutteringbefore gaining a good idea of the childs capacities andthe concerns of the parents

Prevention of relapse, and effective treatment would bepossible only with a comprehensive, complete andcontinuing assessment of the stuttering behavior.

Assessing Fluency Disorders in Adults


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The most fundamental goal during the initial period of

assessment is to understand the clients story.

How a person tell his story reveals importantcharacteristics of the person and his problem.

The client may well have experienced previous treatmentand know something about basic terminology concerningstuttering.

He may have some insight about the therapeutic process.

At the other extreme, a new client may know absolutelyh b h f d


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nothing about the true nature of stuttering anddepending on his cultural background and educationalexperience, bring with him a basket of myths oftenassociated with the disorder.

While some people have a degree of inquisitiveness andopenness about their problem, others will indicateembarrassment and shame.

Our task is to find out where they are on their journey ofchange, their understanding of their situation and theirwillingness to enter into the hard work of making changehappen.


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Generally, although not always, both the surface and thedeep structure of stuttering are more severe and more

obvious in adolescent and adult speakers.

Even at the early stages of stuttering development, some

young children will display well-developed tension (soundprolongation and body movements) and fragmentation(within-word fluency breaks) which are typicallyassociated with advanced or established stuttering

- Schwartz & Conture, 1988; Yairi 1997


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Usually however, older speakers show much greatercomplexity of behavior and exhibit greater anxiety and

fear.

Adolescents and adults have coped and adjusted to the

problems for years.

Thus, the features of their stuttering, especially those

having to do with concealing the problem, tend to be moresophisticated and complex.

B i b l i th li t d l i i h t


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Begin by welcoming the client and explaining whatprocedures will be used to evaluate his problem videotaping and audio taping of his speech, questions

about his past and current difficulties and question abouthis feelings and attitudes regarding his speech.

This followed by analysis of the information and aconcluding interview in which the diagnosis will be sharedwith the client and discuss the things that can be doneabout his problem.

Begin the interview with an open ended question.

Speech Sample


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Pattern of Disfluencies

Throughout evaluation of the adult or adolescentstutterer, clinician observe the pattern with which theclient stutters.

Clinician try to determine for e.g. roughly whatproportion of the core behaviors are repetitions,

prolongations and blocks.


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During blocks, where and how does the stutterer shutoff airflow or voicing?

What are the clients escape and avoidance behaviors?

Is this client able to tolerate being in a block, or does hespeak in an unusual or vague way to avoid stuttering?

This information will be useful when the clinician help theclient reassess more about his stuttering and help himdecrease his fear of it.

Speech Rate


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Rate often reflects the severity of stuttering and the

effect it as having on his communication.

If the clients speech rate is markedly below normal,

communication may be difficult for him.

Rate can be measured as either words per minute orsyllable per minute, depending on the cliniciansperformance.


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Some clinician find it easier to calculate rate using wordsper minute, because words are easily observable units.

Others note that syllables per minute can be calculatedmore rapidly than words because the clinician can use the

beat of the syllable to count on-line (i.e. while thespeaker is talking).

The syllables per minute approach also allows for the factthat some speakers will use more multisyllable words thanothers.

Speakers who use many polysyllabic words mightth is b li d b s th i ds m t k


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otherwise be penalized because their words may takelonger to produce than those who speak using mostlyone-syllable words.

No matter which method is used, the following rules canbe used for counting words or syllables:

1. count only the words/syllables that would have beensound if the person had not stuttered.

Thus, if the person says My-my-my, uh well my name isPeter, this should be considered as 4 words or 5syllables, because it would be assumed that the extramys and the uh are part of stuttering.

f h B h


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If a person says, when I went to Boston, I mean when Iwent to New York and it does not appear that the

person was postponing or using any other trick to avoidstuttering, this would be counted as 13 words or 14syllables, because the persons stuttering did notinterfere with the utterance.

Only words (or syllables in words) are counted uh orum are not counted.

Oh or well are counted, unless they are used as apostponement, starter or other component of stuttering.

Th f h i b l l d b ki h


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The rate of speech is can be calculated by asking thecase read a std passage whose syllable count is known.

The time taken to complete the passage is noted.

Rate - The total no: of syllables/total time taken

Analysis of core behaviors and determining severity:


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Hegde and Davis, 1992 give a description of the major

dysfluency types:

1. Repetitions:

Part word - What ta-ta-ta-time is it?

Whole word - What-Whatare you doing?

Phrase - I want to- I want to-want to do it

2. Prolongations:


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sound/syllable prolongations - Llllllllletme do it.

Silent prolongation

3. Interjunctions:

Sd/syllable - Um-UmI had a problem this morning

Whole word - I had a Wellproblem this morning

Phrase - I had a you knowproblem this morning

Silent pauses


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Broken words

Incomplete phrases

Revisions

Dysfluency Index (DI): Total no:of dysfluencies/ Total no:of words * 100

Indices for each of the stuttering type can also beobtained.


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Percentage syllable stuttered (PSS): Total syllables/

Stuttering * 100

Durational indices: pause time, total articulatory time,fluent articulatory time, stuttering time percentage.

Stuttering Severity Index:


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Given by: Savithri & Jayaram, 1993

A) Average syllable emission rate (ASER):

ASER = FSER DSER,

Where,

FSER = Total no: of syllables uttered during dysfluent

phase/ Total duration of dysfluent phase

DSER = Total no: of syllables uttered during fluent phase/Total duration of fluent phase

B) Stuttering instances:


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PSI = Total stuttering moments/ Total syllables uttered * 100

C) Product of Multiple repetitions:

PMR = OMR x AI,

Where,

OMR = Total no: of multiple repetitions/Total no: of syllables

spoken * 100

AI = Total no: of iterations/ Total no: of multiple repetitions *

100

D) Duration of stuttering instances:


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ADS = Duration of all stuttering instances/ Total no: of

stuttering instances.

SSI= ASER + PSI + PMR + ADS

Assessment of motor behaviors:


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Assessment of prosodic features:

Assessment of self rating of stutterers:

Modified S- scale for self evaluation of stutterers

Assessment of Articulation, Phonation, Respiration:


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Hard articulatory contacts for plosive sounds

Misarticulations

Substitute voiced and unvoiced sounds with each other.

Laryngeal miscoordination

Santosh, 2007 identified errors in articulation byspectrographic analysis:


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spectrographic analysis:

1. Addition of vowels

2. Addition of clicks

3. Errors in place of articulation

4. Errors in manner of articulation

5. Errors in place and manner of articulation

Baverly, 1987 identified delayed phonatory onsets, hardglottal attacks pitch breaks excessive pitch variations


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glottal attacks, pitch breaks, excessive pitch variations,too loud and too soft phonations.

Respiratory features : shallow breathing, audibleinhalation, prolonged inhalation, gasping and a rhythmicalbreathing.

Aerodynamic errors identified by Santosh, 2007

Production of aspirated phonemes for unaspirated and vice

versa

Inspiratory intake between or within words

Instrumental evaluation of stuttering:


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EGG, Spectrography

Glottogram at the moment of stuttering - glottalgestures during stuttering

Chevire-Muller, 1963 used EGG and acoustic data andreported irregularities including hard glottal attack

and clonic flutter in VFs.

Mohan Murthy, 1988 using EGG, electroaerometric andaudio signals showed that stutterers had atypical

i i i i d i f


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transitions, inappropriate duration of segments,inappropriate voicing, inspiratory frication, and

abnormal articulatory constraints.

Santosh and Savithri, 2005 analysed speech of 6stutterers using a wideband spectrogram.

Seven abnormal behaviors were reported.

Stutterers used partial voicing

Partial voicing for unvoiced units

Open glottal gesture with cessation of voice.

Used an airstream characterised by low frequency murmrur


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Used an airstream characterised by low frequency murmrurinstead of voicing.

A murmured plosive substituted for voiced phoneme.

Unvoiced for voiced

Voiced phonemes in place of partially voiced sounds.

Diagnosis/ Differential diagnosis:


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sis

Neurogenic

Stuttering

Psychogenic

stuttering

Cluttering

Assessment of stuttering


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Take case history interview

Obtain a representative speech sample

Analyze core speech behaviors

Determine the severity of stuttering by scales andindices

Assess prosodic features and rate

Assess associated motor behaviors

Assess the articulation, phonation, and respiration

Assess the self rating of stuttering

Summary:


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Evaluating a client who may stutterer or clutterer

(fluency disorders) our task is to decide:

1. If his disfluencies warrant treatment.

2. What are the important characteristics of his history,current environment, speech behaviors and reactions.

3. What treatment do these characteristic indicate.

Most of the tools might answer these three questions,but the most critical is our judgement.


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u m r a ur ju g m n .

Whether the person is to be treated as a normallyspeaker or having fluency disorders depends oninterpretation rather than a score.

We must weigh what we see and hear about his behaviorsto determine if they indicate stuttering, normaldisfluency or any other disorders.

One of the flood of information we gather, we mustdistill the essential characteristics that lead to a choiceof treatment.

REFERENCES:

Kenneth G ; Shipley and Mc Afee J Communicative Disorders: An


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Kenneth, G.; Shipley, and Mc Afee, J. Communicative Disorders: AnAssessment Manual, Chapman and Hall, London, 225-255.

Manning, H.W. (2001). Clinical Decision Making in FluencyDisorders.Singular; Thompson learning

Conture, E.G. (2001). Stuttering: Its nature, diagnosis, andTreatment. Boston: Allyn & Bacon.

Wingate, M.E. (1962). Evaluation and Stuttering, part III:Identification of Stuttering and the use of a label. Journal ofSpeech and Hearing Disorders, 27:368-377.

Guitar, B. (2006). Stuttering: An integrated Approach to its Natureand Treatment(ed.3.). Baltimore: Lippincott Williams & Wilkins

Bloodstein, O. (2002). Early Stuttering as a type of languagedifficulty. Journal of Fluency Disorders, 27:163-167.


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assessment of fluency disorders. / kunnampallil gejo john

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