assessment of fluency disorders. / kunnampallil gejo

7/27/2019 ASSESSMENT OF FLUENCY DISORDERS. / KUNNAMPALLIL GEJO

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KUNNAMPALLIL GEJO JOHN,MASLP

ASSESSMENT OF FLUENCY DISORDERS

INTRODUCTION;

FLUENCY AND DYSFLUENCY

Fluency can be thought of simply as a speakers effortless flow of speech. Thus, a listener who judges a

speaker to be fluent senses that he uses little effort to speak. Starkweather (1980,1987) has suggested

many variables that determines the fluency, it may reflects the temporal aspects of speech production;

that is variables such as pauses, rhythms, intonation, stress and rate are controlled by when and how fast

we move our speech structures. Thus a speaker who speaks with out hesitation, but is slow would not

be considered entirely fluent. In his description of fluency, starweather also includes the effort with

which a speaker speaks. By effort, he means both mental and physical work a speaker must do to speak.

FLUENT SPEECH is continous and the continuity of speech can be disrupted by hesitations of sound,

syllables, words and phrases, prolongation of speech etc.

Rate of speech, defines as the number of syllables uttered per unit of time, is another aspects of fluency.

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

stuttering.

Stuttering is most frequently seen fluency disorder Winnable (1964) defined the term stuttering means:

(a) Disruption in the fluency of verbal expression, which is (b)characterized by involuntary, audibleor silent, repetition or prolongation in the utterance of short speech elements namely; sounds, syllables,

and words of one syllable. These disruption (c) usually occurs frequently or are marked in character and

(d) are not readily controllable (e) some times the disruptions are accompanied by accessory activities

involving the speech apparatus, related or unrelated body structures or stereotyped speech utterance.

Also there are (f) indications or report of the presence of an emotional state ranging from a general

condition of excitement or tension to more specific emotions of a negative nature such as fear,

embarrassment, irritation or the like.

CLUTTERING is another fluency disorder in which speech fluency involves both the rate and rhythm of

speech and resulting in impaired speech intelligibility. Speech is erratic and dysrhythmic consisting of

rapid and jerky spurts that produces grasps of words unrelated to grammatical structures of the sentence.


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REASONS FOR THE EVALUATING SPEECH FLUENCY

There are a number of reasons why a speech language pathologist may be asked to evaluate a childs or

adult speech fluency. Those discussed in this section includes the most common ones.

1) To determines whether the client has a fluency disorder or is at risk of developing one.A clinician is more likely to be asked to evaluate a pre school- age or elementary school-age child to

determine this than an older child or adult, one reason is that such children often have to be evaluating to

assess the need for developing an individualized training program (cooper, 1978). This determination is

often difficult to make for preschool age children because many of them who are normally fluent do a

lot of repeating.

2) To determine the type of fluency disorder

After a clinician has determined that a client has a fluency disorder, he or she usually will attempt to

identify the type. This is important to do, because intervention programs for the various types are not the

same.

3) To identify the set of behaviors that defines the clients fluency (stuttering) problems.

These would include behaviors associated with attitudes and feelings towards speaking abnormally. The

term behavior, as used here, includes what traditionally have been referred to as attitudes and feelings

because both have behavioral components. Information about this set of behaviors can be used clinically

in several ways. First, it can be used to judge the severity of both clients abnormal disfluency behavior

and of his or her fluency problems. A second is to establish presence & or absence of certain behaviors

which affects prognosis. A third way such information can be used clinically is to establish goals for

therapy since the goals for a particular client are determined by the behaviors in this set. It is essential

that they be identified.

4) To assess progress

Clients are re-evaluated periodically to determine whether there is any change in the set of behaviors

that define their problem. They are judged to have improved if there are fewer behaviors in this set or if


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some of those in it have been modified in desirable ways. If there has been little or no change, the

clinician is likely to do further evaluation to determine the reason.

5) To assess the severity of the problem for finding eligibility, litigation and other purposes.

Speech language pathologist occasionally are asked to evaluate speech fluency for a reason other than

rehabilitation. They may be asked top testify as a expert witness about the severity of the problem and\or

the extent to which he or she is handicapped by it (silverman 1992).such an expert opinion may be

requested by an attorney, insurance company, or an organization to the person has applied for finding.

For eg; person has applied to and received funding from state vocational rehabilitation agencies for

educational purposes.

GOALS OF THE ASSESSMENT

A primary goal of clinical assessment is to determine whether the problem exists that would require

treatment, sometimes the severity of the problem and the prognosis regarding treatment cannot be

determine from an initial assessment (Conture, 1997; Guitar, 1998).

Also, the child may effectively use postponement or avoidance strategies that hide any difficulties. In

the case of aberrant or disorganized speech, it may be difficult for the clinician to differentiate between

cluttering, stuttering or a combination of two. Although stuttering for attention is extremely rare, it

remains a possibility. Also, the initial referral may be based on confusion between normal mistakes and

stuttering.

The following figures illustrate the basic assessment procedure:

Initial contact case history form Parent interview Preliminary assessment (Articulation, voice,

language, fluency)

Fluency :- 1) Primary behaviors (multiple part-word repletion, prolongation, pitch or loudness rise, hard

onsets, silent blocks, distortions, struggle & tension, difficulty initiating air flow \ voicing.

2) Secondary behavior (loss of eye contact, eye closure or blinking, head or interjections, revisions,recoils, audible inhalation). The goals of the assessment should be begin an investigation and

exploration of speech behaviors that some one has identified as problematic. The strategies for the

assessment should be selected to obtain information about the problem and create an environment

conductive to allowing the clients o demonstrate, reveal and share feelings and thoughts about the

problems in clinician presence. Only by keeping an open mind will allow the clinician to recognize the


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problem behavior for what it actually is. It means that clinician knowledge must be applied to

objective, scientific inquiry.

Differential diagnosis is an important element of fluency assessment (Ambrose & Yairi 1999, Hill 1999;

onslow & packman 2001). Differential diagnosis not only involved identifying the severity and impact

of the problem displayed by the client, but also means discovering the behaviors that make up the

individuals condition. In addition it is important to document other concomitant and simultaneous

speech and language problems.

STRATEGIES FOR CONDUCTING THE BACKGROUND INTERVIEW:

The assessment process begins from the moment the clinician is contacted by the person needing

therapy or by his caregivers. During initial contact, the activities planned for the assessment should be

explained in a manner that motivates the parents to participate in the assessment process. For eg: a

clinician should provide a rationale for requesting a videotaped language sample or for eliciting a

particular type of speech in the assessment room. The clinician can obtain a feeling for the culture of the

family, including their style of, and expectations for, interacting, that can be helpful in conducting a

productive background interviews.

The objective of the interview with the child and caregivers is to obtain several key types of information.

As long as these are, the interview can be as short or as long as necessary, focusing on the concerns of

the parents and the child, and building rapport among the participants (Hayne & pinzola 1998, contour

2001, hill 2003). It is critical to encourage the parent and child to speak as much as possible and to avoid

long discourses by the clinicians input should be limited as much as possible to asking questions that

elicit detailed and open responses and providing information about specific questions and concerns.

Beginning the interview with a few minutes of relevant light conversation, such as the childs ease or

difficulty in making it to the clinic or plans for the remainder of the day, is a good way of assessing the

communication style to parents and child. It may also provide information about the pace with which

they would like the assessment conducted, and provide important cultural cues that can be used to guide

the interview and assessment process.

Darley and spriestersbach ( 1978) provide some general advice about interviewing style, such as

avoiding yes\no questions, sequencing of questions according to the anxiety level of the information


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building rapport by starting with more factual material and maintaining a brisk pace to obtain more

pertinent information. The clinician must always be prepared for and be willing to welcome and learn

from, expression of emotions that may be encountered or signaled by the behavior of interviewer include

anger, frustration, anxiety, fear, sadness, grief and even indifference. These expressions are not

something to be downplayed, minimized or made better during the interview. They provide critical

information about the effect, personalities and interaction of the caregivers and child.

SOME CONSIDERATION

Before getting into the assessment, a few things to be keep in mind when seeing a new client.

1. Every client is different: - the more experienced the clinician becomes the tendency to jump toconclusion. Be caution about letting referral information, past experience and other sources could

our ability to see all aspects of the client and his problem. For instance, a child parents tell us that

they often ask their child to stop and start again when he stutterers, try not to assume that

pressures at home are the major problem for the child. They may be, but other things may be

critical also. Ask more questions.

2. Consider the person as well as the problem:- The client , no matter what age, will sense quicklywhether we are seeing him as an individual or only seeing his stuttering. An effective clinician is

genuinely interested and empathetic, she accepts failures backslides as well as victories and

profess. The evaluation is our first opportunity to show the client that you accept him just as he is

and do not reject or fear his stuttering. In this atmosphere, the client can start to accept him

selves and his stuttering and make the first critical steps towards fluency.

3. Diagnosis is an ongoing process: - As treatment process (ordoesnt)try to keep asking, am Iusing the best approach with this person? Is there something else or something different I should

be doing? Decide what measures of proffers are important for our client and apply these

measures at regular intervals. Assess a client after every ten hours of treatment. Also assess the

clients stuttering when we bring them in for maintenance checks at increasingly wider intervals

after formal treatment is over. Also assess the clients feelings and attitude at the beginning and

end of treatment.


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ASSESSING FLUENCY DISORDERS IN CHILDREN

Evaluation of the characteristics of a fluency disorder and the effect that disorder has on a patients

ability to communicate is a crucial first step in designing an appropriate program of management. The

evaluation process involves the gathering of pertinent information (case history) from the patient and

also from the care takers, as well as collecting data on the patients performance of various tasks. This

information enables the speech pathologist to diagnose the fluency disorder, determine the relative

efficacy of various treatment approaches and formulate a prognosis.

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).

1. Evaluation and description of the dysfluency of the child:Description should be in terms of the type of disruptions/blocks, frequency, duration, severity and the

associated non speech behaviors.

Types of disruptions/blocks: Look for core behaviors (Van Riper, 1982): repetitions(being stuck on a sound/syllable/part word and continue repeating until the following

sound is produced), prolongations (sound continues but the articulators dont move,

usually more than half a second) and blocks (inappropriate stopping of voice/articulatory

movements). Other types of blocks like interjections, revisions, and pauses may also be

observed.

Frequency and duration of blocks: Children who stutter differ from each other on thefrequency and duration. Usually stuttering frequency is greater than 5% and the average

duration of a block may be around a second. Higher the frequency and longer the

duration, the more severe the stuttering,

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


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2. Evaluation and description of the speech and language production in general:

Language performance Mean length of utterance Rate of speech during instances of stuttering and fluent productions Voice aspects during stuttering instances Articulatory proficiency Oral peripheral mechanism Prosody Intelligibility of speech

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

2002). Researchers have discovered that children who stutter follow the same linguistic pattern as that of

adults who stutter more on pronouns and conjuctions than nouns, verbs, adjectives and adverbs. In

children the loci is identified as the beginning of syntactic units (sentences, clauses and phrases) and not

as words initial positions. This is viewed as a difficulty in linguistic planning and preparation

(Bernstein Ratner, 1997). Conture (2001) directs attention to phoneme selection component of linguistic

planning in children who stutter. So there seems to be associations with phonological skill, / speech

production rate and speech motor systems skill / potential to execute fluent speech. Reports suggest that

nearly 2445 % of children who stutter exhibit some degree of articulation / phonological difficulties (

Louko, Conture& Edwards, 1999 ) . So evaluation should include aspects of language, phonology and

other speech dimensions.

3. Describe the developmental history ( speech and language )Speech and language development history is important for us to make decisions of the capacity of the

system to cope up with the processing load during speech and language acquisition proceeds rapidly

than his developing motor system or is delayed causing frustration and difficulty in speaking, can be

ascertained by nothing developmental history .

4. Track the pedigree


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Stuttering tends to run in families and is more common in males than females (Kidd , 1984 ; Ambrose

, Cox & Yairi , 1997 ; Felsenfeld, 1997 ). However, the exact percentage of occurrence in families and

gender ratio is still not clear. These genetic studies assert biological predisposition towards children

who are more likely to stutter. Keeping aside the complex ( confusing for a clinician) conclusions from

the genetic studies , the clinician should expect that if there was a family history of stuttering , there is

more likely a chance to impose a strong negative feeling about the disorder on the child . Such feelings

need to be explored and discussed during the interview. This is important both in assessment and

treatment.

5. Evaluate the temperament and emotional stability of the childMost children these days have very low emotional tolerance and they are often hypersensitive. This

might be due to results of over protection and expectations on the child childs performance in any

activity of interest to the parents. Guitar (2006) also suggests that understanding the temperament of

the child. Increased physical tension during stuttering instances might be expected of a child due to his

reactive temperament, and may lead to chronic stuttering. While on the other hand, a child with placid

temperament may be more relaxed and will probably ignore / accept stuttering, thereby may outgrow /

cope with the problem more easily.

6. Evaluate the three As of the concerned: awareness, anxiety and attitude towardsstuttering.

Awareness of the problem , anxiety that arises before , during and after stuttering spells and the

attitude that one develops will reflect on the childs and the patients emotional reactions towards

stuttering . These emotional reactions may range from fear , guilt and embarrassment to complete

helplessness and depression. These negative feelings need to be combated and analysis of the As will

facilitated the unlearning of the fear based stuttering behaviors in the child.

When to evaluate?


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Evaluate as soon as the concern arises. The concern may be raised by the parents, family and friends,

school and the child him / her self. The typical age at which the onset of stuttering is repeated is

between two and four (Conture, 2001). 70% of children with developmental stuttering have a gradual

onset and nearly 50 75% improve without any forma; treatment (Guitar 2006). Guitar also

summarized the factors to be associated with the chances for natural recovery from stuttering, and they

include the following:

1. Good language and phonological skills2. Good motor ( non verbal ) skills3. No family history of stuttering and natural recovery from it in the family members.4. Early age of onset and5. Being a female.

Evaluation closer to the age at which the concerns arise is essential so that either intervention can be

started or the parents can be asserted regarding spontaneous recovery.

How and Where to evaluate?

For both clinical as well as research purpose, often times we would require to make categorical

judgments regarding stuttering and fluent speech. To arrive at this decision one necessarily need to

conduct an interview and also observe the child, the concerned and their interactions and behaviors.

Assessment using standardized tests like stuttering severity instruments (Riley) may be done.

Comparison with norm references may seem useful in occasions to diagnose, differentially diagnose

and arrive at the degrees of severity of the problem.

Case History Form:

Informs the clinician about the parents perception about the problem, at present, as well as its onset

and development, and the childs medical and family history and school history. This information is

used as a starting place for further questions during the parent interview. It is important to appreciate

that this initial meeting with the child and the parents is the first opportunity for the clinician to show

her understanding about both the general nature of stuttering and the impact it can have on the child


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and his family. This is the first chance for her to begin making the problems less mysterious, to

respond to some of the myths or mis-information that the family 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. As Contour (1997) suggests, the clinicians ability to orientate the

family to the true nature of the problem may be the main benefit that the child and the family receive

from the diagnostic meeting(s).

Parent Participation in Assessment:

The motivation for initiating treatment may be minimal if the family physician or friends and family

members suggest that the problem will likely go away by itself (Ramig, 1993c) Rustin & Cook (1995)

suggested the most important aspect of the interview process is the clinicians style and ability to be

flexible and creative as she interacts with the parents. Talking more freely about stuttering directly

with preschoolers, as well as with their parents may reduce parents distress about their childs

stuttering; perhaps talking about stuttering openly reduces everyones fear on it. During parent

interview, the clinician gives them an opportunity to talk about the matters that they feel and also 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 the remainder of the evaluation. Clinician should assure them that, there will be a time for

sharing the assessment information and recommendation with them at the end. Usually during the

assessment the clinician used to asks open-ended questions. Open ended questions allow the parents

to describe their concern in their own words. When parents have had a chance to describe the problem

and appear to have no more to say at that moment, clinician should ask about the first stages of the

childs life (the childs birth and development) and then work up toward the present time. In the

ensuing conversation, the clinician showed be sure that he/she gets information indicated by the

questions which is mentioned below.

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

Although there is little evidence that stutters, as a group, have difficult birth histories, there is

an increased incidence of stuttering among brain-damaged individuals (Boehme, 1968; Poulos &

Webster, 1991). If a difficult pregnancy or birth is reported, the clinician should examine the childs

motor and cognitive development more closely. The case history form, which is completed before the


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evaluation provides preliminary information about birth history that may or may not need to be

followed up.

2) What was the childs speech and language development like? How did it compare with

siblings development and with your expectations?

Because, the first appearance of stuttering may be influenced by the processing load that

language acquisition has on speech production, it is important to understand the course of a childs

overall speech and language development. Clinician explore the possibility that a childs language

acquisition is proceeding so rapidly that the motor system cannot keep up with it. Clinician should

also examine the possibility that a childs language development is delayed and he is frustrated and

finding it hard to talk. There is some evidence that poorer language skills are predictive of persistent

stuttering.

3) Describe the childs motor development compared with that of his brothers, sisters or other

children?

Some indicators of the normal range of gross and fine motor development, as well as personal,

social and speech language development, can be found in the Denver Developmental Screening Test

(Frankenberg & Dodds, 1967).

According to Barry & Guitar, many children who stutter appear to slightly advanced in their

language and, to a lesser extent slightly delayed in their motor skills. In either case, these children

seem to benefit from models of speech produced at slow rate. Other children who stutter may be

delayed in several areas; they may need treatment for language and articulation that is integrated with

therapy for stuttering.

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

After asking this question generally, clinician should specifically ask whether family members

or other relatives have ever stuttered, had articulation or language disorders or have been clutterers.

To confirm that disorder was a problem, clinician usually ask if the person ever received treatment.

Clinician can use this information while discussing stuttering as a disorder that may have predisposing

factors. Handled tactfully, this discussion of predisposing factors helps parents realize that their

childs stuttering was not something they caused. This in turn, can help them be more effective in

facilitating the childs fluency.

If a parent stutters, or used to stutter, he or she may have strong negative feelings about the

disorder, including guilt; such feelings need to be discussed in the initial interview and throughout any


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treatment the child receives. The way in which a parent handles stuttering is also important because

this behavior will serve as a model for the child.

If relatives of the child stutter, it is important to find out whether or not they recovered.

Research cited earlier found that among children who were identified within 6 months of the onset of

stuttering, those with relatives who did not recover from stuttering were more likely to have persistent

stuttering than those with relatives who did recover. After getting background information, turn to

onset and development of the childs stuttering.

5) When was the Childs disfluency first noticed?

If treatment is begun soon after the child starts to stutter within a few weeks or months, rather

than a year or more. Another reason is now much time has passed since onset is that most of the

predictive information on chronicity of stuttering is based on children identified within 6 months of

onset. Yairi, Ambrose, Paden (1996) children who recovered from their stuttering began to show a

steady decline in stuttering within the 12 months after their stuttering was first identified. Children

whose stuttering persisted for at least 3 years did not show such a decline. Therefore, knowing how

long it has been since the onset of a childs stuttering helps the clinician to make treatment decisions,

based on findings that some children are likely to recover without therapy.

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

This may provide some leads about the kinds of pressure to which a child may be vulnerable,

which can help clinicians determine what changes the parents can make to reduce stuttering. Events

that may contribute to the onset of stuttering include the birth of the siblings, moving to a new home,

and growth spurts in language or cognition. Many times, there are no special circumstances at the

onset of stuttering, which should be acknowledged to parents so they do not feel that they are to blame

for the stuttering.

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

Most of the stuttering begins with easy repetitions, although some children begin with prolongation

and blocks as well. Some preliminary information suggests that when repetitions sound quite rapid

(when the pause between repetition units is brief), a child is more likely to be stuttering rather than

being normally disfluent (Allen, 1988, Throne burg & Yairi, 1994). These rapid sounding repetitions

may be predictive of persistent stuttering (Yairi, Ambrose, Paden & Throneburg, 1996). This

difference cannot be diagnosed accurately without instrumentation, but a practiced ear can help a


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clinician perceive the brevity of pauses between repetition units. This information should be used only

in support of an overall patterns of findings that help the clinician decide whether or not to recommend

treatment.

8) What changes, if any, have been observed in the childs speech since stuttering was first

noticed?

The changes the clinician most interested include frequency of disfluencies, types of disfluencies and

periods of remission. Children whose frequency of stuttering disfluencies (part-word and single-

syllable whole word repetitions, prolongations and blocks) does not decrease during the 12 months

after onset are at risk for becoming persistent stutterers. According to Barry & Guitar, if a childs

physical tension and struggle during stuttering are increasing or if stuttering is becoming more

consistent and less intermittent the child is beyond the borderline level of stuttering and treatment

should be considered.

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

If the child appears to have no awareness, clinician will be more likely to categorize him as normally

disfluent or as a borderline stutterer than if he notices or seems concerned by his disflulencies. If he is

aware that he has difficulty speaking or shows frustration, he may be a beginning stutterer. Note that

such awareness may not be negative, but just a neural level of awareness at early stages. Indications

of the childs awareness include such things as his commenting on his stuttering either when it occurs

or at some other time, and the fact that other people have brought it to his attention. Awareness is also

suggested if a child stops when he is dysfluent and starts again or if he laughs, cries or hits himself

when he stutters. Even without any of these signs, a child may still be aware of his stuttering.

In some instances, preschool children may show more than just neural awareness and frustration: they

may show negative feelings about talking and may have fear of certain words. They comment that

they wished they could speak like someone else or may show some word avoidances.

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

Parents are usually able to guess this is happening because they can sense the childs apprehension

about saying a word. Clinician should also ask if the child changes words in mid stream, that is does

he start a word, get stuck on it, and then change it? Both behaviors are not good signs and may

indicate that the child is moving toward the intermediate stage of stuttering development.

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


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Again, this is most parents know because they sense the childs fear of talking and like the

word avoidance, this may indicate an intermediate level of stuttering.

12) What do the parents believe caused the problem?

In some cases, parents may have ideas, which clinician believes are appropriate and accurate,

about the possible cause of their childs stuttering. In other cases, parents belief about the causal

factors may be incorrect. Clinician should be particularly sensitive to whether or not parents blame

themselves or each other for their childs stuttering. Clinician should tell them that some children may

have slight differences in their neurological organization for speech, which may emerge as stuttering

during the normal stresses and strains of growing up and learning to talk. The parents should know

they did not cause the childs stuttering, but they should also know that they can play a key role in

childs learning to deal with it.

13) How do the parents feel about the childs disfluency problem?

Parental influence will obviously influence the child. Counseling may be needed to alleviate

these feelings. If the parents feel guilty, counseling to relieve guilt is important. If the child is

normally disfluent, but the parents are overly concerned, counseling can be directed at relieving this

concern.

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

This question is aimed at finding out how the parents have responded to the childs disfluency.

For e.g. have they asked the child to slow down or stop and say the word again. This will direct

clinician for counseling. If parents are correcting the child, clinician may ask them first to observe,

then participate in treatment, so that they may develop appropriate ways of responding.

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

This information can be important in planning therapy and counseling parents. For example, if their

family doctor has told them the child will outgrow stuttering, their experience needs to be dealt with;

since they now are less convinced he will outgrow it. If the child has been in other treatment, it is

important to know what advice the parents were given. Sometimes, parents have been given excellent

advice but were not able to follow it. We need to find out why and to help them change their

responses. We sometimes find that parents have had their child in successful therapy but have moved

away and sought us out to continue the same kind of treatment. In these cases, we try to contact the

previous therapist and explore with the parents what was done, so that we can continue to work in the


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same direction as before. In some cases, parents come to us seeking a second opinion, and we are able

to reinforce what others have said, if we agree. In other cases, they may have been advised to ignore

the childs stuttering, and we may tactfully discuss the possibility of going in an entirely different

direction.

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

disfluency?

This information helps to identify fluency disrupters and fluency facilitators. We will want to use this

information to help parents facilitate the childs fluency and have found it effective to point out,

whenever possible, all the helpful things the parents are already doing. Just the awareness that their

childs stuttering responds to environmental cues, and thereby has some logic to it, helps most parents

to feel more competent to manage it.

After we believe that we understand a childs current stuttering behavior, we ask about social and

emotional development.

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

We usually find that children who stutter relate fairly well to others, but we want to find out if a

childs stuttering is interfering with his relationships. Sometimes, when asking this question, we learn

about pressure and competition from siblings or tensing by a neighborhood bully.

18) What is the childs personality and temperament like?

Some children who stutter are more sensitive and fearful than other children. A child with this

temperament may benefit from extra help in developing self-confidence.

19) Is there anything else you can think of to tell us that will help us better understand your

childs stuttering?

Sometimes, it is not possible to direct questions to all areas of concern, and this question

provides an opportunity for parents to provide information that we have not thought of asking.

Child Interview

Following questions can be ask during child interview.

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

If a child regards his problem as minor or seems genuinely unaware of a problem. Clinician tries to

avoid giving it undue emphasis or create an unfavorable attitude about it.


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

times?

Here clinician should look for several things. One is to learn the words that the child uses to describe

his stuttering so that clinician can use them when talking with him about it. Clinician should also find

out if the child is unaware of some of his stuttering behaviors and if they seem to be too painful for

him to face. Or if he just doesnt like to talk about them. Even more important, these questions let the

child know the clinician really wants to understand his problem.

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

With this question clinician can convey that we understand what some people often do when they

stutter. Clinician can also let the child know that we are non-judge oval about the tricks he uses, by

conveying acceptance and interest in his descriptions. In addition clinician can also explore which

level the childs stuttering has reached by determining if he is using escape and avoidance behaviors.

4) Are certain speaking situations more difficult? Does he avoid them?

Again this question will help clinician to understand what the child is experiencing while conveying

that understanding.

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

does he react?

Many children who are teased are not willing to talk about it. Straight away with some one they dont

know well. So this question is a feeli and if the child denies being teased, the clinician should not

dwell on it now.

6) How does the child feel about his speech?

To help a child express feelings about stuttering, the clinician can ask few questions like Do you wish

you didnt stutter? Etc.,

A real discussing of feelings probably wont begin until a child learns to trust the clinician deeply. But

in this first interview, clinician may be able to infer what some of the feelings are and from that,

understand how far the childs stuttering has advanced.

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

This helps clinician to determine what sort of learning experiences the child may have been going

through at home. One parent may be much less accepting of a childs stuttering than the other.

Whatever clinician determine may help us to enlist the parents participation in treatment.


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8) Ask the child, can you think anything else important for me to know about you or about the trouble

you sometimes have when you talk?

This is a chance to let the child know that we are interested in him and that we value his ideas.

PARENT-CHILD INTERACTION

When possible, clinician should observe one or both parents interacting with their child. It is better to

do this at the beginning of the evaluation for several reasons. First, parents may be less affected by

clinicians orientation toward stuttering and may thereby give the clinician more natural sample.

Second, this interaction gives clinician a chance to see the childs stuttering first-hand. For e.g. how

much the child seems aware of the stuttering, how much accessory behavior there us, and whether or

not the child appears embarrassed. Third clinician can observe the way in which the parents interact

with their child.

The parent-child interaction can be done formally or informally. Some clinician observe the

interaction in the waiting room and make only mental notes, some may visit the childs home and

some uses videotape recording of the parents and the child in the play style interaction in a treatment

room supplied with toys and games.

CLINICIAN-CHILD INTERACTION

Here, the clinician can see directly what the childs disfluency is like, how he responds to various cues

and to what extent the childs disfluency is modifiable. Always better to do this interaction tape-

record for later analysis. If videotape is available, it is preferable, since visual cues are sometimes

critical in determining a childs developmental/treatment level.

Clinician focuses their interaction on toys or games suitable to the childs age. Clinician should talk in

an easy, relaxed manner much like they advice parents to do. If the child is stuttering similarly to the

way the parents have described, clinician keeps the same speech style throughout the interaction.

However, if the child is entirely fluent or normally disfluent and the parents have described behaviors

which a clinician feels are stuttering, clinician speeds up the speech rate and ask many questions.

Occasionally, clinician interrupt at some point to elicit the disfluent speech, which is perhaps more

characteristic. They do this to avoid misdiagnosing a child who is stuttering as a normally fluent

speaker.


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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 their observation in non-directive play to assess his

speech. If it is pretty clear, from earlier information or from clinicians own observation, that client is

aware, then try to determine how able the child is to talk about his stuttering. This gives clinician an

opening to go further and discuss his stuttering with the child. Some clinicians will help a child talks

about his stuttering by first telling the child about another child who stutters (Bloodstein, personal

communication, 1990). In discussing stuttering with a child, clinician usually try to use their

vocabulary such as getting stuck or having trouble on words.

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

(a)To see if the child is accepting of himself and his disfluencies enough to discuss them.(b)To indicate to the child that he is not alone with the problem and moreover we may be able to

help them.

A Child Who Wont Talk

A very shy child may start to cry and along to his parents. Our suggestion would be not to force the

child to separate. Its more important to have the child positively inclined toward the therapy situation

rather than having unpleasant memories of his first visit, even if we dont get all the information we

want. In this situation, clinician talk with the parents in one part of the 10 cm while another clinician

plays with the child in another part. Clinician talk few minutes about general things, letting the child

become familiar with the clinician with whom hes interacting. Then clinician may suggest to the

parents that we and they move into an adjacent room but keep the door open. With this arrangement,

clinician can usually talk about sensitive matters without being overheard. At times, certain children

will separate from their parent, but wont interact with clinician during evaluation. Then avoid asking

direct questions. Instead play with the child. After several minutes, clinician usually find that the

child relaxes and begin to speak spontaneously. After this continues let several more minutes,

clinician can begin more direct interactions. Only after the child gets quite comfortable, clinician

attempt to discuss his trouble talking.

A Child who is entirely Fluent


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Some children may be entirely fluent during the evaluation. In these cases, there are several options.

First, the tape recording, that the parent sent the clinician, may have a good enough sample of

stuttering to use it for speech sample. Second, if the child is use a particularly fluent episode, clinician

may reschedule him for evaluation at a later time.

TO DETERMINE WHETHER OR NOT THE CHILD IS STUTTERING

During the assessment of the children, there will be occasions when the very behaviors, the clinician

wants to observe and evaluate are not present. On such occasions the clinician may choose to elicit

these behaviors. That is, the clinician assessing the young child must be prepared to introduce various

forms of communicative stress during the assessment.

Eliciting Fluency Breaks: There are many benign techniques the clinician may use to elicit fluency

breaks in children. Essentially what clinician are doing is creating a speaking situation where

temporarily, the demands we are placing on the child exceed his ability to use his speech production

system. For e.g. turn away as the child is describing an event or activity. Loss of listeners attention

has long been known as a powerful technique for eliciting fluency breaks in children (Johnson, 1962,

Van Riper, 1982). The clinician may ask the child to respond quickly to a series of questions or ask

him to answer somewhat abstract or difficult to answer queries (Gitar & Peters, 1980). Depending on

the age of the child he or she could be asked to read from books that are somewhat above his grade

level (Blood & Hood, 1978 or asked to describe a series of pictures which are presented at a rapid rate

so that he is unable to formulate a complete response.

It is not necessary to elicit many of these breaks. Once a few examples have been obtained, the

clinician can consult with the parents to determine it these behavior they have observed and are

concerned about.

Support for the importance of observing children in a variety 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 usual disfluency types for each of the children

as they look part in 3 to 5 of the following situation.

1) Parent with pressures imposed2) Play


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3) Play with pressures imposed4) Story retell5) Picture description

He found that these children who stuttered showed significantly more variability across the speaking

situation than within any single situation. He also found that children who produced a higher overall

frequency of less typical disfluencies also exhibited greater variability.

No significant correlation was found for the more typical fluency breaks. Finally, the play with

pressure situation resulted in the greatest number of disfluencies, although this was not the case for

all the participants, as many children exhibited highly individualized patterns.

Based on these results, Yaruss (1997a) suggested that sampling of a childs fluency in a single

speaking situation is unlikely to result in a representative sample of behavior, particularly for children

who exhibit a greater number of stuttering like disfluencies.

DETERMINING A CHILDS LEVEL OF ANXIETY ABOUT SPEAKING

Interest in investigating levels of anxiety in children began to occur in the 1990s. Although research

to date does not suggest that stuttering is caused by anxiety, it is more reasonable to assume that

anxiety is a consequence of stuttering. Two types of anxiety have been identified and have been the

focus of research. Trial anxiety has to do with the persons general level of anxiety and is obtained by

having the client respond to self-report scales containing questions about how he or she generally feel.

Measures of state anxiety are intended to indicate a measure of a persons anxiety response at a

specific moment as he or she react to specific situational stimuli. A frequently used measure of

anxiety is the state-trait anxiety inventory for children (STAIC) developed by Spielberger, Edward,

Monture (1972). Score on both Stale & Triate sub-scale range from 20 to 60, with high score

representing greater anxiety. Using the STAIC, Craig & Hancock (1996) found no significant

differences between 96 untreated children who stuttered and 104 children who did not stutter (age

range 9-14 years). In addition, the authors found no significant association between stuttering

frequency and state anxiety.

SPEECH SAMPLE

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

interaction and the clinician child interaction. Clinician choose the sample that has the greatest


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amount of stuttering for the most detailed analysis, but also note the extent of stuttering/fluency on the

other samples.

The Nature of the Fluency Breaks

Yairi (1997) recommends a speech sample of at least 500 syllables. The following guidelines are

based on a per-100-syllable disfluency metric stuttering like disfluencies are indicated as SLD and

short element repetitions (Syllable and word repetition) are indicated as SER.

Behavior Preschool Children who Stutter

1. Total number of disfluencies per 100 syllables Average of 16

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

3. Percent SLD to total disfluencies Range of 60% to 75%

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

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 100 syllables

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 SER

containing one extra unit

Mean of to 1/3

Conture (1997) also suggests that clinicians consider a number of subtle signs that may help to

distinguish the possibility of stuttering.

Within-word disfluencies that average 3 or more per 100 words (minimum of 300 wordsample)

Sound prolongations in 25% or more of the childrens No. of fluency breaks.


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An average differences of two or more syllables per second in speaking rates of the motherand children during conversational speech, increases in the occurrence of simultaneous-talk

by the child and parent, and greater amounts of parent-child interrupting behaviors.

The presence of stuttering, stuttering clusters in the childs two element speech disfluencyclusters.

Eye ball movements to the side, eye blink during stuttering or both. Clusters of two or more within-word breaks on adjacent sounds, syllables or words within

an utterance.

Pattern of Disfluencies

In this analysis, clinician get information about whether or not the child is stutterer and, if so, what

developmental/treatment level he belongs in clinician analyze six variables, listed below, to begin this

determination (Adams, 1977, Curlee, 1980).

1) Frequency of disfluencies

This is calculated on the entire sample, and is expressed as the number of disfluencies per 100

words. Both normal disfluencies and those associated with stuttering are included in this count.

Normally, disfluent children usually have fewer than 10 disfluencies per 100 words.

2) Types of disfluencies

Identified 8 types of disfluencies: Part-word repetition, single-syllable word repetition, multisyllable

word repetition, phrase repetition, interjections, revisions-incomplete phrases, prolongations and tense

pauses. Children who are normally disfluent are more likely to show revisions and multisyllable

whole-word repetitions. Below age 3 they will also show interjections. Part-word repetitions,

prolongations and tense pauses are more characteristics of stuttering children.

3) Nature of Repetitions and Prolongations:

There are several dimensions to this variable. First, normally disfluent are more likely to have only

one extra unit to their repetitions: li-like this. They may sometimes have two. But, as the No. of

repetitions increases, so does the likelihood that the child is a stutterer. Second, we listen to the tempo

of the repetitions. If they are slow and regular, the child is more likely to be appropriately categorized


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as a normally disfluent speaker. If they are rapid ands irregular, it is more likely we will treat the child

as a stutterer. Third, we observe the degree of tension in both the repetition and prolongations. Both

visual and auditory cues help here; tension can be seen in facial expression and heard in increased

pitch and more staccato voice quality. Children whom we would label as normally disfluent do not

often show tension in their disfluencies.

4) Starting and sustaining airflow and phonation

The children whom we are likely to categorize as a stutter will show difficulty here. He will have

abrupt onsets and offsets of words especially repeated words. He may also show momentary pauses

with fixed articulator position at the onset of words. Moreover, transitions between words may be

abrupt, jerky or broken.

5) Physical Concomitants

Here, clinician 100K for physical gestures that accompany disfluencies, especially those that

are timed to the release of the disfluent sound. Examples are head nods, eye blinks, hand or finger

movements. Here, we also include extra noises such as the sounds of the child gritting his teeth or

clicking his tongue.

6) Word avoidancesAnother sign which we sometimes see in a disfluent child, that suggest that he stutters is word

avoidance. This can be blatant, as when a child starts a word and then changes it, as in pu -pu-pu

dog or it may be more subtle, as in saying I dont know when it is clear that he does.

If the child shows any of the characteristics of stuttering described above, he showed be

considered at least a borderline stutterer.

Determining the Likelihood of Chronicity

Assuming that the young childs fluency breaks are considered to be unusual or abnormal, the next

clinical decision is whether this pattern is likely to continue developing.

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, head or general body movements may also

indicate the need for intervention. However, if these signs are less evident, the best clinical choice is


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questionable. A family history of stuttering and the parents concerned response 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 of stuttering (Conture & Caruso,

1987, Onslow 1992, Riley & Riley 1983).

On the other hand, if there is no family history of stuttering and parents and other caregivers are

unconcerned about the childs speech, it may be advisable to monitor the child for approximately 3

months, as investigations by Yairi, Ambrose & Niermann (1983) suggest that there is a tendency for

children to recover within 3 months following onset.

There is a real possibility that the stuttering behaviors will decrease and even cease. This decrease has

been termed spontaneous recovery, unassisted recovery and natural remission. Although the estimated

number of these young speakers who obtain fluency without intervention varies widely from

approximately 32% to more than 80% (Andrews & Harris 1964, Bryngelson 1938, Cooper 1972,

Curlee & Yairi 1997, Brutten 1999, Stark weather 1987, Van Riper 1982, Young 1975). It is certain

that a significant number of children do recover. Some authors have suggested that these relatively

high rates of spontaneous recovery have come under question (Martin & Lindamood 1986, Ramig

1993a).

One important consideration is the gender of the child. Andrews et al. (1983) report that from 5 to 10

times more males than females stutter. Recent data suggests however, that gender may be more of an

indicator of recovery form-rather than occurrence of stuttering. That is recent studies of young male

and female children indicate that the gender ratio is 50-50. young boys and girls are equally as likely

to demonstrate abnormal fluency breaks.

Stuttering Severity Index (SSI)

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 of 150 words

for analysis. The child may also be engaged in conversation, and if this sample shows more stuttering

than the picture description, it should be used for the analysis. Clinician typically use a 5 minute

sample, rather than a 150 word sample, because it is easier to ensure that we have a complete sample.

Frequency of stuttering, mean duration of the three longest stutterers and physical concomitants are

scored and the total is computed. The total score permits a labeling ranging from very mild to very

severe.


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Speech Rate

Clinicians assess the rate of childrens speech using the speech sample obtained for the SSI. Speech

rates for three age groups of non-stuttering preschoolers have been obtained by Rebekah Pindzola,

Melissa Jenkins & Kari (1989). Children in their study were asked a series of questions from 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 each of 3 age groups. They found, for 3

year olds; 116-163 SPM for 4 year olds; 117-183 SPM and for 5 year old 109-183 SPM. Differences

between age group were not statistically significant, and no comparisons between males and females

were made. Data on words per minute are not available.

Feelings and Attitudes

Clinician assesses the feelings about stuttering by asking about them in the parent interview, by

observing the parent-child interaction and by bringing up the topic of stuttering. Feelings and attitudes

in the children may range from apparent unawareness of difficulty, to mild embarrassment, to extreme

hypersensitivity. A child may for e.g. look slightly uncomfortable when clinician ask him why he is

here, but he may venture that its because he has trouble talking. At the other extreme, a child may cry

at the prospect of talking to someone about his speech and he may be deeply embarrassed and

uncommunicative even if the clinician gingerly approaches the topic of speech or getting stuck.

The assessment of feelings and attitudes of the children leads clinician to conclude tentatively whether

the child (a) unaware of his disfluenices (b) occasionally aware and rarely bothered by them (c) is

aware of them and frustrated by them (d) highly aware of them, is frustrated by them and afraid of

them.

Other Speech and Language Behaviors

Clinician should also screen for articulation, language and voice problems and also make sure

that childs hearing has been checked recently and if not, clinician should arrange to have a hearing

screening.

A childs language and/ or articulation problems can usually be detected in the parent -child or

clinician-child interaction when clinician find apparent delays in these areas, they should administer a

formal test.


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Research suggests that one of the pressures on a child who stutters may result from language that is

significantly advanced over motor development. Thus, an evaluating a childs language and

articulation, clinician explore the possibility that his language is above average for his age. In addition

clinician should observe and question parents about general motor development as well as about

intelligibility of speech.

According to Barry & Guitar a few children have obvious motor problem that may impair their co-

ordination of respiration, phonation and articulation with language production. These children seem to

benefit especially from models of slow speech as well as specific activities that teach the child to

speak more slowly.

In addition to exploring the possibility of language and articulation difficulties, clinician also assesses

the childs voice. A hoarse voice may be especially significant in the preschool stutterer because it

may signify that the child is using considerable tension in the laryngeal muscles to cope with

stuttering. Clinician should closely look at how the child is handling his blocks and listen for signs

and excess laryngeal tension, such as pitch rises and hard glottal attacks. However, if the child has

other voice problems besides hoarseness or if hoarseness does not diminish with stuttering therapy, the

clinician may want to refer the child to an otolaryngologists and follow a treatment approach (Wilson,

1979).

Assessing Fluency Disorders in Adults

The most fundamental goal during the initial period of assessment is to understand the clients story.

How a person tell his story reveals important characteristics of the person and his problem. The client

may well have experienced previous treatment and know something about basic terminology

concerning stuttering. He may have some insight about the therapeutic process. At the other extreme,

a new client may know absolutely nothing about the true nature of stuttering and depending on his

cultural background and educational experience, bring with him a basket of myths often associated

with the disorder. While some people have a degree of inquisitiveness and openness about their

problem, others will indicate embarrassment and shame. Our task is to find out where they are on

their journey of change, their understanding of their situation and their willingness to enter into the

hard work of making change happen.

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

severe and more obvious in adolescent and adult speakers. Even at the early stages of stuttering


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development, some young children will display well-developed tension (sound prolongation and body

movements) and fragmentation (within-word fluency breaks) which are typically associated with

advanced or established stuttering (Schwartz & Conture, 1988; Yairi 1997). Usually however, older

speakers show much greater complexity 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 more sophisticated and complex.

We begin by welcoming the client and explaining what procedures we will use to evaluate his problem

videotaping and audio taping of his speech, questions about his past and current difficulties and

question about his feelings and attitudes regarding his speech. This followed by our analysis of the

information and a concluding interview in which we will share our diagnosis with the client and

discuss the things that can be done about his problem. We begin our interview with an open ended

question.

Speech Sample

Pattern of Disfluencies

Throughout evaluation of the adult or adolescent stutterer, clinician observe the pattern with which the

client stutters. Clinician try to determine for e.g. roughly what proportion of the core behaviors are

repetitions, prolongations and blocks. During blocks, where and how does the stutterer shut off airflow

or voicing? What are the clients escape and avoidance behaviors? Is this client able to tolerate being in

a block, or does he speak in an unusual or vague way to avoid stuttering? This information will be

useful when we help the client reassess more about his stuttering and help him decrease his fear of it.

Speech Rate

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 or syllable per minute, depending on the

clinicians performance. Some clinician find it easier to calculate rate using words per minute, because

words are easily observable units. Others note that syllables per minute can be calculated more rapidly

than words because the clinician can use the beat of the syllable to count on-line (i.e. while the

speaker is talking). The syllables per minute approach also allows for the fact that some speakers will

use more multisyllable words than others. Speakers who use many polysyllabic words might otherwise


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be penalized because their words may take longer to produce than those who speak using mostly one-

syllable words. No matter which method is used, the following rules can be used for counting words or

syllables: count only the words/syllables that would have been sound if the person had not stuttered.

Thus, if the person says My-my-my, uh well my name is Peter, this should be considered as 4 w ords

or 5 syllables, because it would be assumed that the extra mys and the uh are part of stuttering. If a

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

the person was postponing or using any other trick to avoid stuttering, this would be counted as 13

words or 14 syllables, because the persons stuttering did not interfere with the utterance. Only words

(or syllables in words) are counted uh or um are not counted. Oh or well are counted, unless

they are used as a postponement, starter or other component of stuttering.

When words per minute are calculated, a transcript is made of the clients 5-minute sample of

conversational speech and his 5 minute reading sample is marked to indicate whether he finished. Total

number of words are counted and this figure is divided by 5 to give a per minute conversation or reading

rate.

The normal speaking rate has a range of about 115 to 165 words per minute (Andrews &

Ingham, 1971). Normal reading rate has a range of about 150 to 190 words per minute (Darley &

Spriestersbach, 1978).

When syllables per minute are calculated, it is often easiest to use an inexpensive calculator to

count syllables cumulatively, as they are being spoken. Before the speaker begins push the I key, then

the t. When the speakers starts speaking, depress the = key for each syllable spoken or read. The

cumulative total appears in the readout window.

Normal speech rate has a range of from 162 to 230 syllables per minute, with a mean of 196

(Andrews & Ingham, 1971). Normal reading rate is about 210 to 265 syllables per minute.

Feelings and Attitudes

A variety of questionnaires are available to assess various aspects of the stutterers feelings and

attitudes about communication and about stuttering. We obtain information about the clients

communication attitudes via the Modified Erickson Scale (Andrews & Cutter, 1974). This

questionnaire illustrated in figure 6.4 has been normed on both stutterers and non-stutterers. More over,

research has suggested that changes in attitude during treatment may be related to long term outcome


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(Guitar & Bass, 1978), although there is debase in the literature about the interpretation of this finding

(Ingham 1979, Guitar 1979, Young 1981).

We also use questionnaire to assess the clients tendency to avoid stuttering. We use the

avoidance scales of the stutterers self rating of Reactions to speech situations (Johnson, Darley, 1952),

which will be referred to as SSRto assess the tendency to avoid specific speaking situation. This form

is shown in figure 6.5.

We may also use Perception of Stuttering Inventory (PSI) (Woolf, 1967) shows in figure 6.6

which examines the stutterers perception of the presence of struggle, avoidance, and expectancy of

stuttering in his communication. Woolf suggests the PSI can be used to help the stutterer view his

problem more objectively, to develop treatment goals and to assess progress.

Stuttering Severity Instrument-3 (SSI-3)

Identifying Information

Name: Age/Sex Date

DOB School Examiner

Pre-school School Age Adult: Reader Non-Reader

Frequency

READERS TABLE NON-READERS TABLE

1) Speaking Task 2) Reading Task 3) Speaking Task% Score % Score % Score

1 2 1 2 1 4

2 3 2 4 2 6

3 4 3-4 5 3 8

4-5 5 5-7 6 4-5 10

6-7 6 8-12 7 6-7 12

8-11 7 13-20 8 8-11 14

READERS TABLE NON-READERS TABLE

1) Speaking Task 2) Reading Task 3) Speaking Task


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% Score % Score % Score

12-21 8 21 & up 9 12-21 16

22 & up 9 22 & up 18

Frequency score

(use 1+2 or 3)

Duration

Average length of 3 longest stuttering events timed to the

nearest 1/10th

second

Scale score

Fleeting (.5 sec or less) 2

Half-second (.5 - .9 sec) 4

1 full second (1.01.9 sec) 6

2 seconds (2.02.9 sec) 8



10 seconds (10.029.9 sec) 14

30 seconds (30.039.9 sec) 16

1 minute (60 sec or more) 18

Duration score (2-18)

Physical Concomitants

Evaluating Scale: 0 = none

1 = not noticeable unless looking for it

2 = barely observable to casual observer

3 = distracting

4 = very distracting

5 = severe and painful looking

Distracting sounds Noisy breathing, whistling,

sniffing, blowing, clicking

0 1 2 3 4 5


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sounds

Facial Grimace Jaw jerking, tongue

protruding, lips pressing,

jaw muscles tense

0 1 2 3 4 5

Head Movements Back, forward, turning

away, poor eye contact,

constant looking around

0 1 2 3 4 5

Movements of the

extremities

Arm & hand movements,

hands about face, torso

movements, leg

movements, foot-tapping or

swinging

0 1 2 3 4 5

Physical Concomitants Score

Total Overall Score

Frequency .. Duration . Physical Concomitant

Percentile ..

Severity .

PERCENTILE AND SEVERITY EQUIVALENCE OF SSI-3 TOTAL OVER

ALL SCORES FOR PRE-SCHOOL CHILDREN (N=12)

Total Overall Score Percentile Severity

0-8 1-4 Very mild

9-10 5-11 Very mild

11-12 12-23 Mild

13-16 24-40 Mild

17-23 41-60 Moderate


27-28 78-88 Severe

29-31 89-95 Severe


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32 & up 96-99 Very severe

For School Age Children

Total overall Score Percentile Severity

0-8 1-4 Very mild

9-10 5.11 Very mild

11-15 12-23 Mild

16-20 24-40 Mild



28-31 78-88 Severe

32-35 89-95 Severe

36 & up 96-99 Very severe

For Adults

Total Overall Score Percentile Severity

10-12 1-4 Very mild

13-17 5-11 Very mild

18-20 12-23 Mild

21-24 24-4- Mild



32-34 78-88 Severe

35-36 89-95 Severe

37-46 96-99 Very Severe

Scale for Rating Severity of Stuttering

Speaker: Age: Sex: Date:

Rater: Identification

Instruction


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Indicate your identification by some such term as Speakers Clinician

Clinical Observer, Clinical Student, or Friend mother, Classmate etc., Rate

the severity of the speakers stuttering on a scale from 0 to 7 as follows:

0 No stuttering

1 Very mildstuttering on less than 1% of words; very little relevant tension,

disfluencies generally less than 1 sec. in duration; patterns of disfluency

simple; no apparent associated movements of body, arms, legs or head.

2 Mildstuttering on about 1-2% of words; tension scarcely, perceptible very

few, if any, disfluencies lastas long as a full second, patterns of disfluency

simple; no apparent associated movements of body, arms, legs or head.

3 Mild to moderatestuttering on about 2-5% of words, tension noticeable but

not very distracting, most disfluencies do not very distracting, most

disfluencies do not last longer than a full second, patterns of disfluencies

mostly simple; no distracting associated movements.

0 No stuttering

4 Moderate - stuttering on about 5-8% of words, tension occasionally

distracting; disfluencies average about one second in duration; disfluency

patterns characterized by an occasional complicating sound or facial grimace;

an occasional distracting associated movement.5 Moderate to severe stuttering on about 8-12% of words; consistently

noticeable tension; disfluencies average about 2 seconds in duration; a few

distracting sounds and facial grimaces; a few distracting associated

movement.

6 Severe-stuttering on about 12 to 25% of words; conspicuous tension;

disfluencies average 2-4 sec in duration; conspicuous distracting sounds and

facial grimaces; conspicuous distracting associated movements.

7 Very severe stuttering on more than 25% of words; very conspicuous

tension; disfluencies average more than 4 SPL in duration; very conspicuous

distracting sounds and facial grimaces, very conspicuous distracting

associated movements.


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Other Speech and Language Behaviors

As we interact with the client during the interview, we informally assess his

comprehension and production of language, his articulation and voice. We also screen

his hearing. If we suspect that there is an articulation, language or voice problem, we

follow up with further evaluation in the potential deficit areas.

Perhaps we should place a voice problem in a separate category. We sometimes find

that stutterers may be hoarse. We feel that many times this may be the result of

laryngeal tension related to stuttering. If stuttering treatment is successful, the

hoarseness may disappear. If the hoarseness is of recent origin, we may refer the client

for an otolaryngological exam to rule out a serious laryngeal pathology.

Other Factors

In this section, we will be discussing evaluation of the following factors:

Intelligence, academic adjustment, psychological adjustment and vocational

adjustment. Each of these can affect the treatment of the adult or adolescent stutterer

and therefore, must be considered in planning therapy.

If a stutterer has below normal intelligence, he may have difficulty following the

regimen of a typical therapy program. Adolescent stutterers in the schools will usually

be identified as mentally handicapped if they are, and they are likely to be, in a special

class. Adults, too are usually previously identified as mentally handicapped if such is

the case, because either the referral source will indicate this or it will be evident that a

guardian has filled out the case history form.

There is no group differences between stutterers and nonstutterers in their degree of

psychological health. However, we sometimes see stutterers who do not function well

in their environments. They may be unable to hold a job, or they may be socially

withdrawn. The clinician should be alert to the effect these adjustment problems may

have on treatment. If clinician suspects, as treatment progresses (or does not), that

psychological problems are interfering with treatment, she may wish to refer these

clients for psychological help.

Psychological problems relevant to stuttering may also become apparent in the

interview when the onset of stuttering is explored. Sudden onset after a psychological


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trauma, particularly, if the onset is in late adolescence or adulthood, may indicate

psychogenic stuttering. If the psychological effects of the trauma have subsided, the

adolescent or adult client may respond well to the treatment approach. If it is clear that

psychological factors are still affecting the clients speech and behavior or if there is

doubt, refer the client for a psychological evaluation.

Interview with Parents of Adolescent

When we evaluate an adolescent stutterer, we want to talk with this parents to

obtain more background information about the client, to give them an opportunity to

express their concerns and feelings privately and let them know what we will be doing

with their child.

We begin the initial interview with the parents of the adolescent stutterer by

asking them to describe the problem as they see it. We try to get an understanding of

how the young client functions within his family. We usually ask questions such as

the: what is their childs stuttering like at home? How does he feel about it? Is he

embarrassed or does he show fear of talking or anger? How do the parents feel about

it? What are the family members reaction to it? What do they do when he stutters?

Has their child been anywhere else for therapy? If so, what were the results? Etc.,

Adolescents strive to become more and more independent from their parents.

Therefore, we find that therapy works best if the adolescent is treated as an adult. We

begin fostering this independence by first talking to the teenaged client separately from

his parents so that he can give us his own view of the situation and how he views the

prospect of treatment. Following this and following our meeting with the parent,

described above, we meet with the parents and the teenaged client together to find

mutual agreement about the parents and teenager role in treatment.

Diagnosis

After gathering the information described above, clinician need to integrate this

material to determine, if the client stutters and if so, what treatment level would be

appropriate. Typically clients in this age range will be advanced stutterers. However,

some of the adolescent stutterers may be in the intermediate stage.


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In rare cases, individuals who are normally disfluent, though perhaps highly

normally disfluent, may be referred by teachers, employer or friends. These individual

will have phrase repetition, circumlocutions, revisions and hesitations. These types of

disfluencies are relatively infrequent after their school years.

However, some adolescents and adults may simply be on the disfluent and of

the continuum of normal fluency. In addition to differences in the unit-size of their

disfluencies, they will be clearly distinguishable from stutterer because they will have

neither secondary behaviors nor negative feelings and attitudes. Our role in these case

is to explain to the individual and to the referring person, that these disfluencies are

normal and need not be concerns.

Another need for differential diagnosis, besides in instances of normal

disfluencies. Is in cases in which cluttering, neurogenic disfluency and psychogenic

disfluency need to be distinguished from stuttering. Moreover, it is also necessary to

rule out the disfluency caused by word-finding difficulties that we might find in persons

with learning disability.

Some of the salient features of cluttering in adults and adolescents are rapid,

sometimes unintelligible speech, frequent repetition of words, syllables or phrases, lack

of awareness or concern about the speech, disorganized thought processes and language

problems.

Neurogenic disfluency in the adolescent or adult is usually the result of stroke,

head trauma or neurological disease symptoms are likely to be disfluencies, but may

include blockage as well. Stuttering commonly begins in childhood, if a client reports

onset of stuttering after age of 12, a neurogenic-based disorder is a possibility.

Disfluency that begins in adolescence or adulthood can also result from

psychological trauma. Carole Roth, Arnold Aroma & Leo Davis (1989) indicate that

psychogenic disfluency often arises during periods of environmental stress or

interpersonal conflicts. Disfluencies included repetitions, prolongations, blocks,

secondary behaviors and feelings and attitudes similar to those of stutterers.

Psychogenic disfluency was generally found to be amenable to traditional

psychotherapy and stuttering treatment approaches, both during diagnostic interview

and later during treatment. However, not all psychogenic disfluency responds to


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treatment in summary, when late-onset disfluencies are seen and are associated with

psychological stress and conflict and the onset of a psychiatric condition, psychogenic

disfluency should be suspected. The patient should be referred fro both psychological

and neurological assessment, so that treatment needed in these areas will be provided.

Advanced Stuttering

The individual who fits into the advanced developmental / treatment level is 14

years or older and sufficiently mature to handle the assignments used in advanced

treatment. This stuttering pattern is similar to the intermediate stutters but his pattern

of avoidance and escape may be more habituated. He will probably avoid difficult

speaking situations whenever possible as well strong negative self-concepts and

anticipated negative-listener reactions.

Closing Interview

By this point in the evaluation, we have a pretty good picture of his stuttering

and where we will start therapy. We begin by summarizing our impression of his

stuttering pattern (Core & secondary behaviors) and his attitudes and feelings.

We then outline the particular type of therapy we have chosen. With

adolescents, we may end our evaluation session by striking a bargain to try at least four

sessions of therapy before they make a decision about treatment. We can also give

them booklet.

Assessing Speaking Rates for Children and Adults

Many clinician believe that speaking rate of ten reflects the severity of stuttering

(Shapiro 1999; Stark weather 1985, 1987). If a clients speaking rate as well below

average for her age, communication will be affected; listeners may become impatient or

lose the thread of what the speaker is saying. Speaking rates that are too fast will also

affect communication. Following table shows the speaking rates for children and

adults.

Age

(Year)

Range in syllables per minute Reference

3 116-163 Pindzole, Jentons & Loken

assessment of fluency disorders. / kunnampallil gejo

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