Assessment of Fluency Disorders Stephen Tasko Speech Pathology and Audiology Western Michigan University

What is a fluency disorder?  Stuttering Developmental stuttering Psychogenic stuttering Neurogenic stuttering  Cluttering

(Developmental) Stuttering Common Features  Breakdown in the fluidity and rhythm of speech  Breakdowns include Sound repetition Audible and silent prolongations  Typically occurs at the beginning of utterances  May fluctuate a great deal across situations  Stuttering influenced by environmental, linguistic and other communicative pressures  May delay (postpone) or avoid saying certain words/sounds etc  Can have associated symptoms including overt body movements such as facial twitches, grimaces, head jerking, extraneous limb movement etc (secondary behaviors)  Can have associated symptoms of anxiety, shame, fear and guilt

(Developmental) Stuttering Natural History of disorder  Begins in early childhood (preschool)  Early stuttering may be difficult to distinguish from normal disfluency  Features of stuttering tend to change over time  Spontaneous resolution is not uncommon Prevalence: roughly 1% of population Lifetime incidence: ~ 4-5 %  In developed form, expectancy, fear and avoidance play significant roles

(Developmental) Stuttering Who tends to stutter?  Those with a family history of the disorder  Slower developing/disordered speech and language  Boys more likely to stutter than girls  Children who are “vulnerable” to stress*

Neurogenic Stuttering Neuropathology  Distinct from aphasia, dysarthria, apraxia  Observed following lesions to Left and right hemisphere All lobes except occipital lobe Cortical and subcortical (BG; thalamus) structures Some Features  Part-word or phoneme repetitions  No patterns related to word type  Not restricted to initial words  No syllable stress effect  Lack of anxiety or secondary symptoms  Less responsive to fluency- enhancing conditions

Psychogenic Stuttering  Stuttering secondary to emotional trauma or stress Some Features  Sudden onset, typically related to some event  Repetition of initial or stressed word  Fluency enhancing effects not observed  No periods of stutter free speech  Initially no interest in problem

Cluttering  Daly, 1992 “Cluttering is a disorder of speech and language processing resulting in rapid, dysrhythmic, sporadic, unorganized, and frequently unintelligible speech. Accelerated speech is not always present, but an impairment in formulating language almost always is.”

Ten Significant Features of Cluttering: Expert Opinion (Daly & Cantrell, 2006) Characteristic  Telescopes or condenses words  Lack of effective self-monitoring skills  Lack of pauses between words; run-on sentences  Lack of awareness  Imprecise articulation  Irregular speech rate  Interjections; revisions; filler words  Compulsive talker; verbose; circumlocutions  Language disorganized; confused wording  Seems to verbalize before adequate thought formulation Agreement (%)

Stuttering vs. Cluttering  Pure cluttering considered relatively rare Is it rare or do pure clutterers not seek treatment?  Cluttering-stuttering more common Clinical reports of about 1/3 of youngsters who stutter show signs of cluttering

The Assessment Process  Case History  Evaluating Attitudes Toward Problem  Evaluating Stuttering Behavior  Diagnostic Probes  Summarizing and Making Recommendations

General Considerations  Build rapport  Age  Audiotape session (videotape if possible)

Case History

Problem Description  General What is the problem? Why is this a problem  Specific 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?

Problem Description continued  History When did it start? Who identified it? Why do you think it started? Summarize the history of the stuttering.

Problem Description continued  Family history of stuttering  Medical history  Pregnancy  Family constellation  Developmental information Speech and language Intellectual Physical Emotional

Problem Description continued  Attitudes Toward the Problem 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? The measurement of attitudes and attitude change are essential parts of successful treatment!!

Attitude Scales  A-19 Scale for children who stutter 19 Y-N questions  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 35 T-F questions Older children can self administer, younger children can be asked questions

Additional Information Self rating of problem  Overall  How representative is speech today? Therapy history and attitudes toward therapy  Therapy history  Expectations of therapy

Evaluating stuttering behavior  Counting and sorting disfluencies  Physical descriptions of disfluency  Stuttering instruments  Noting associated behaviors

Counting and Sorting Disfluency Types of disfluency  Sound, syllable, word or phrase repetition  Sound, syllable, word or phrase revision  Prolongation  Tense Pause (Block)  Interjection  Revisions  Circumlocution Counting disfluencies  % stuttered syllables/% stuttered words  Units vs. moments of disfluency

Physical description of disfluency  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 description of disfluency Physiologic variables to consider  Voicing  Muscle Tension  Movement (stoppage, choppiness)  Rate of Speech  Airflow/Aerodynamics With additional consideration given to  Effort, caution, tentative vs. free

Do behaviors serve a purpose? For example,  Postponement  Avoidance  Starter behaviors  Escape behaviors

Early disfluency vs. stuttering Common observations in young children  Whole-word repetition  Sentence initiation  Normal tempo  Lack of awareness or concern  Evidence of language formulation stress  Episodic

Summary by Yairi (1997) Relative to normally fluent children, children who stutter exhibit  2-3x total disfluencies  5-6x stuttering-like disfluencies (SLD)*  ↑ proportion of SLD/total disfluency  ↑ proportion of part-word repetitions with ≥ 2 units  6x disfluency ‘clusters’  Longer disfluency clusters  Repetitions with shorter successive interval between units  2x associated head and neck movements *SLD= part-word repetition, disrhythmic phonation, tense pause

Things to look for in youngsters During Speech  Frequency of disfluency  Type of disfluency  Evidence of struggle  Rhythm of stuttering  More adult patterns  Associated behaviors  Awareness, fear and frustration Other risk factors  Gender male  Family history Positive family history  Speech language status Concomitant speech/language issues  Duration >14-18 mos.  Age of onset Onset after 3.5 yrs

Speech Samples  Reading aloud  Picture Description  Monologue: Job Description  “Problem” areas (e.g. telephone)

Variables known to influence fluency  Automatic speech Counting  Choral speaking Use difficult material  Whispered speech Use difficult material  Altered speech rate Say it fast/slow  Applying stress to client

Associated Behaviors

Selected Test Instruments  Stuttering Severity Instrument (SSI-3)  Overall Assessment of the Speaker’s Experience of Stuttering (OASES)  Provile of Stuttering Behavior

Stuttering Severity Instrument: SSI-3 (Riley, 1994)  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

Overall Assessment of the Speaker’s Experience of Stuttering (OASES)  New Instrument (Yaruss and Quesel, 2006)  Multi-faceted assessment tool  Based on WHO definitions of health & disability  Designed for adults  Relatively quick to administer (~20 minutes)  Undergone validation with normative data

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

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

Diagnostic Probes

Summarizing and Making Recommendations