Assessment

Frameworks for thinking about assessment and intervention Basic knowledge of stuttering guides the components of the assessment process ABCs of stuttering (various) Affective Behavioral Cognitive Yairi & Seery (2015) Overt Speech Physical Concomitants Physiological Activity Affective Features Cognitive Processes Social Dynamics CALMS (Healey, 2004) Cognitive Affective Linguistic Motoric Social

Goals of assessment Establish the diagnosis For adults/older children, diagnosis is often established Differential diagnoses: developmental vs. acquired (psychogenic vs. neurogenic) Stuttering vs. cluttering Stuttering vs. other communication disorders For younger children, a diagnosis may need to be established However, parents are often pretty good at making the diagnosis – few false positives Presence of concomitant disorders Establish the client-specific dimensions of the disorder History of problem Behavioral, affective, cognitive and social aspects of problem

Goals of assessment Make a prognosis Predict how things will proceed With young children, predict likelihood of recovery vs. persistence Determine management approach No intervention Close monitoring Indirect intervention Direct intervention

Dimensions of assessment Case history Self report tools Speech evaluation Interpretation of findings Prognosis and planning

Case History Problem Description General Specific What is the problem? Why is this a problem Specific Specific behaviors – be willing to demonstrate them Conditions when worse/better How do you get out of a stutter? How do you prevent a stutter? How do others react to your stuttering? How do you react to your stuttering and others reactions to it? Can you predict or anticipate your stuttering?

Case History Problem description continued History of stuttering problem When did it start? Who identified it? Why do you think it started? Summarize the history of the stuttering

Special considerations: Early stuttering Establishing early history is very important When did the child begin stuttering? What were the initial signs or characteristics? Demonstrate different types of disfluency Rate severity How did it happen? What were the circumstances surrounding the event? What other factors might have been involved? Who might be a contributor? Combine this with getting a pedigree How has the stuttering progressed?

Case History Related Background Information Family history of stuttering Determine near relatives with problem Differentiate whether stuttering persisted or resolved Particularly important with young children with a recent onset of stuttering If possible establish a pedigree

Pedigree: example

Case History Related Background Information Medical history Pregnancy Family constellation Developmental information Speech and language Intellectual Physical Emotional/behavioral

Case History Attitudes toward speaking and stuttering Has your reaction to stuttering changed? Perceptions of others reactions and how you would prefer them to react Situational avoidance (speaking and nonspeaking) Do you feel like you have control over your speech or does it control you? Do you feel fear and shame associated with stuttering? In addition, use an attitude scale to document views The measurement of attitudes and attitude change can be essential parts of successful treatment!!

Case History Therapy history Self rating of problem Details about past therapy Views about past therapy Expectations of therapy Self rating of problem Overall rating of problem How representative is speech today?

Sheehan’s stuttering “iceberg” Relative contribution of overt and ‘internal’ water-line Overt symptoms iceberg “Internal” symptoms

Special considerations: Early stuttering Getting at awareness & affective reactions in the young child Ask parents about awareness and reactions of child and their own reactions to stuttering Sample questions: Do you like to talk? Are you a good talker? Do you make mistakes when you talk? Clinician can stutter and use that as a point of discussion: I just had a bump in my speech. Do you ever get that? Puppet use: one puppet stutters, the other does not and have child identify which talks like him/her

Special considerations: School age stuttering Teacher’s attitude toward student’s speech Impact of stuttering on classroom participation Problems with teasing/bullying

Dimensions of assessment Case history Self report tools Speech evaluation Interpretation of findings Prognosis and planning

Self report scales can measure Behavioral aspects of stuttering Role of Speaking Situation Attitudes, fears and thoughts about speech and stuttering Impact of stuttering on daily life

Measuring the Role of Speaking Situations Speech Situation Checklist (Brutten, 1965, 2003) Stutterers Self-Rating of Reactions to Speech Situations (Darley & Spriestersbach, 1978)

Measuring thoughts and attitudes: Attitude scales Revised Erickson scale Original items drawn from MMPI 24 T-F items with normative data Perceptions of Stuttering inventory (PSI) 60 questions 3 themes, struggle, avoidance, expectancy Children’s attitude test (CAT) 35 T-F questions Older children can self administer, younger children can be asked questions A-19 Scale for children who stutter 19 Y-N questions

Other questionnaire-based scales Purdue Information Questionnaire for Stutterers Locus of Control of Behavior Scale

Behavior Assessment Battery for School-Age Children Who Stutter (BAB) Includes The Speech Situation Checklists (SSC-ER and SSC-SD) speech disruption in a range of speech situations a child's emotional reaction to speech situations The Behavior Checklist (BCL) reveals particular coping responses that a child uses to deal with disfluency The Communication Attitude Test (CAT) measures a child’s attitude about his or her speech

Overall Assessment of the Speaker’s Experience of Stuttering (OASES) Newer instrument (Yaruss and Quesel, 2006) Based on WHO definitions of health & disability Designed for adults Relatively quick to administer (~20 minutes) Undergone validation with normative data NEW VERSIONS OASES-S – for school age children 7-12 OASES-T –for teens 13-17

International Classification of Functioning (ICF) From Yaruss, (2005)

Why do we consider more than just the stuttering behaviors?

Components of the Stuttering Disorder INTERACT From Yaruss, (2005)

The Personal Identify of Stuttering PERSISTS Personal identity (or construct) of being a person who stutters can persist, even after the speaker has tools for “managing” speech “Changes under the surface and over time” Personal constructs can change and such change requires specific effort in therapy Need to measure the outcomes of therapy efforts Adapted from Yaruss, (2005)

EBP REQUIRES Comprehensive Measurement evidence-based practice require that clinicians and researchers collect data about the treatment they provide Every issue or characteristic that is addressed in treatment must be evaluated If treatment addresses anything other than fluency, broad-based measurement is required Adapted from Yaruss, (2005)

People Who Stutter Do More Than Just Stutter Personal histories by people who stutter highlight the broad impact of the disorder Census of NSA Members (McClure & Yaruss, 2003) Stuttering interferes with school/work (79%) and social/family (64%) interactions Many feel embarrassed about stuttering (70%) and avoid speaking situations (82%) This is true even after treatment! From Yaruss, (2005)

Overall Assessment of the Speaker’s Experience of Stuttering (OASES) Four content areas Section I: General Information Assesses self-perception of impairment, fluency, speech naturalness Assesses knowledge about self-help and treatment options. Section II: Your Reactions to Stuttering Assesses the affective, behavioral, and cognitive reactions to stuttering Section III: Communication in Daily Situations Assesses the client’s situational difficulties (work, social, home) Section IV: Quality of Life Assesses the negative impact of stuttering on the client’s life. 100 questions Yield 4 focused scales, plus an overall scale

I. General Information Part A: About your speech… How often are you able to speak fluently? How often do you say exactly what you want to say even if you think you might stutter? Part B: How knowledgeable are you about…? Factors that affect stuttering Self-help or support groups for people who stutter Part C: Overall, how do you feel about…? Your speaking ability The way you sound when you speak Your ability to use techniques you learned in speech therapy ( From OASES Manual)

II: Your Reactions to Stuttering Part A: When you think about your stuttering, how often do you feel…? Helpless Angry Guilty Frustrated Part B: How often do you…? Experience physical tension when stuttering Avoid speaking in certain situations or to certain people Not say what you want to say (e.g., avoid or substitute words, refuse to answer questions, order something you do not want because it is easier to say) Part C: To what extent do you agree or disagree with the following statements. I think about my stuttering nearly all the time. When I am stuttering, there is nothing I can do about it. I cannot accept the fact that I stutter. ( From OASES Manual)

III: Communication in Daily Situations Part A: How difficult is it for you to communicate in the following general situations? Talking with another person “one-on-one” Talking with people you do know well (e.g., friends) Continuing to speak regardless of how your listener responds to you Part B: How difficult is it for you to communicate in the following situations at work? Talking with co-workers or other people you work with (e.g., participating in meetings) Talking with your supervisor or boss Part C: How difficult is it for you to communicate in the following social situations? Participating in social events (e.g., making “small talk” at parties) Ordering food in a restaurant Part D: How difficult is it for you to communicate in the following situations at home? Talking to your spouse / significant other Taking part in family discussions ( From OASES Manual)

IV: Quality of Life Part A: How much is your overall quality of life negatively affected by…? Your reactions to your stuttering Part B: Overall, how much does stuttering interfere with your satisfaction with communication...? At work In social situations At home Overall, how much does stuttering interfere with your…? Part C: Relationships with family Relationships with other people Part D: Ability to do your job Ability to earn as much as you feel you should Part E: Sense of self-worth or self-esteem Enthusiasm for life Sense of control over your life Spiritual well-being ( From OASES Manual)

Dimensions of assessment Case history Self report tools Speech evaluation Interpretation of findings Prognosis and planning

Aspects of speech behavior analysis Speech sample collection Disfluency analysis Use of stuttering instruments Speech rate Other measures

The speech sample: What to include? Within clinic and home recorded samples Spontaneous Speech Free conversation Structured spontaneous speech activities For example, Procedural narratives Picture description Oral reading Multiple readings help establish adaptation and consistency of behavior Selected situations known to create difficulty Telephone calls Speaking to strangers Introduction of time pressures

The speech sample: What to include? Include tasks that are known to influence fluency “automatic” or “non-propositional” speech e.g. counting Choral speaking Use difficult material Whispered speech Altered speech rate “Say it fast/slow” If available, use of altered feedback device to determine if it serves as a fluency facilitator

Speech sample: Procedures Audio vs. video Video-recording greatly aids making judgments of core stuttering and physical concomitants Use a good lapel microphone if possible Length of sample As long as practically possible is recommended Most consider 300 syllables to be an minimum Other argue for samples larger that 600-1000 syllables Recording over multiple sessions can enhance validity of data For young children, Yairi (2005) recommends 30 minutes of speech recorded over at least two sessions

Aspects of speech behavior analysis Speech sample collection Disfluency analysis Use of stuttering instruments Speech rate Other measures

Evaluating stuttering behavior Frequency of disfluency Type of disfluency Severity/duration of disfluency Physical/motoric descriptions of disfluency Physical concomitants Hypothetical “purpose” of behaviors

Frequency of disfluency Common metrics Is the reference words or syllables? Percent stuttered syllables/words Number of disfluencies per 100 syllables/words What is the difference?

Considerations When Counting Syllables/Words Repetitions and interjections ARE NOT included. Revisions ARE included. Unfinished or abandoned words varying views on this issue Yairi and Seery suggest to include them Consider the following a single word Common expressions (e.g. ‘oh yeah’) Acronyms (e.g. ‘IRS’) Proper names (e.g. ‘Joe Perry’) Concatenated forms (e.g. ‘gonna’) Ritualized reduplications (e.g. ‘so-so’)

Considerations When Counting Syllables/Words Do not include the following within the main analysis Direct quotes Lists or series of words Sung or recited words Isolated single word utterances indicating (e.g. ‘yes’ or ‘no) Unintelligible words or syllables

Break down by type of disfluency Stuttering like disfluencies (SLD) Part word repetition Single-syllable whole word repetition Disrhythmic phonation Prolongation Blocks/tense pause Other disfluencies (OD) Interjection Multi-syllable word or phrase repetition Revision or abandoned utterance While designed for young children, the classification scheme is useful for identifying and categorizing disfluencies Illinois Longitudinal Studies (ILS) Disfluency Classification System

Duration/severity of disfluency For repetitions, the number of units matters For prolongations, the duration of longer examples matter

Physical/motoric description of disfluency As the disfluency unfolds in time… How does the speech pattern change prior to breakdown? What is happening at the moment of breakdown? How does the client release from the breakdown?

Physical/motoric description of disfluency What is happening with respect to… Voicing Muscle Tension Movement (stoppage, choppiness) Rate of Speech Airflow/Aerodynamics With additional consideration given to Effort, caution, tentative vs. free

Physical concomitants Overt concomitants Elevated muscle tension Tremor Altered speech breathing patterns Speaking at/to very low lung volumes Gasping and speaking on inhalation Vocal abnormalities Glottal fry Falsetto Abnormal intonation patterns Unusual Interjections/Interruptors Excessive pausing Extraneous body movements Skin reactions Bloodstein (1995) Van Riper (1982)

Do any behaviors appear to serve a purpose? Avoidance devices Postponement devices Starting devices Escape devices Adapted from Van Riper (1963)

Aspects of speech behavior analysis Speech sample collection Disfluency analysis Use of stuttering instruments Speech rate Other measures

Stuttering Severity Instrument (SSI, SSI-R, SSI-3, SSI-4) Provides a percentile rank and “severity” rating based on a composite of scores based upon Frequency of disfluency Duration of disfluency Presence of physical concomitants Measurements based on Spontaneous speech and reading when literate Picture description if not literate

Test of Childhood Stuttering (TOCS) Ages 4-12 years Administration time: 20-30 minutes Main Purpose Identify children who stutter Determine severity of stuttering Document change in status

TOCS: Components Standardized Speech Fluency Measure Rapid picture naming Modeled sentences Structures conversation Narration Observational rating scale Information from parents, teachers and others Supplemental Clinical Assessment 8 supplements for more detailed analysis

Yairi & Ambrose (2005)

Parent Stuttering Severity Scale (Yairi & Ambrose, 1992) Helpful for establishing change over time Parents rate stuttering at time of onset and currently 0-7 scale (Midpoint ratings are acceptable) 0: normal fluency 1: borderline 2: mild 3: mild to moderate 4: moderate 5: moderate to severe 6: severe 7: very severe

Profile of Stuttering Behavior (Van Riper) Developed to measure Frequency Intensity Duration Postponement/avoidance Provides a profile that is well suited for evaluating therapy progress

Aspects of speech behavior analysis Speech sample collection Disfluency analysis Use of stuttering instruments Speech rate Other measures

Measuring speech rate Rate of information flow Speech rate Articulatory rate Also consider rating of speech naturalness

Speaking rate Negatively correlated with stuttering severity Slow speaking rate = higher severity CWS generally speak a little slower than NFC

Aspects of speech behavior analysis Speech sample collection Disfluency analysis Use of stuttering instruments Speech rate Other measures

Adaptation and Consistency What is adaptation? Reduced frequency, intensity and/or duration of disfluency over repeated readings of a passage. Most notable between the first and second reading, but may be observed over a number of readings. Neurogenic stuttering typically does not adapt and in some cases stuttering may increase with repeated readings.

Hypotheses regarding adaptation motor practice* anxiety reduction reduced stress on language formulation psychological suggestion *Recent empirical support for this notion

Adaptation and Consistency What is consistency? degree to which a person consistently stutters on a particular phoneme or word, or at a particular location in a word or sentence during repeated readings of a passage. Anecdotal evidence suggests that high consistency is a negative prognostic indicator.

Measuring Adaptation Using percent stuttered syllables (% SS) A= % SS in first reading B= % SS in second reading % Adaptation= (A-B)/A X 100 Using oral reading rate A=duration of first reading B=duration of second reading

Measuring consistency: The consistency index Percentage of stuttering moments in second reading that were stuttered during the first reading For example, Reading 1: 100 disfluencies Reading 2: 25 disfluencies were repeated Consistency index = 25/100 = 25%

Consistency continued In addition to the consistency index, it is important to note the consistency of Difficulty with voiced productions Difficulty with certain plosive or continuant types Patterns of difficulty with stressed or nonstressed syllables Consistency with which secondary (accessory) behaviors accompany disfluent patterns

Special consideration to the child who stutters Need to rule out problems with Receptive and expressive language Phonology and articulation Keep a general eye on Motor skills

Dimensions of assessment Case history Self report tools Speech evaluation Interpretation of findings Prognosis and planning

What to do with the data? For the confirmed person who stutters Establish a pattern of behavior for monitoring progress (with or without therapy) Establish an overall severity estimate Useful for guiding intervention strategies

What to do with the data? For the unconfirmed child who stutters Determine if pattern of behavior is consistent with stuttering Establish a pattern of behavior for monitoring progress (with or without therapy) Establish an overall severity estimate Useful for guiding intervention strategies

Making a functional link (original located on website)

Dimensions of assessment Case history Self report tools Speech evaluation Interpretation of findings Prognosis and planning

Prognosis: Issues Prognosis for persistence vs. recovery Prognosis for therapy benefit

Prognosis for Therapy Benefit Not well studied Some factors to consider Degree of motivation Past therapy experiences Outcome Expectations Flexibility varying speech motor behavior use diagnostic therapy techniques