1. Assessment

2. 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

3. 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

4. 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

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

6. 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?

7. 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

8. 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?

9. 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

10. Pedigree: example

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

12. 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!!

13. 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?

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

15. 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

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

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

18. 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

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

20. 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

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

22. 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

23. 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

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

25. Why do we consider more than just the stuttering behaviors?

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

27. 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)

28. 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)

29. 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)

30. 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

31. 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)

32. 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)

33. 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)

34. 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)

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

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

40. 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

41. 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

42. 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 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

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

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

45. 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?

46. 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’)

47. 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

48. 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

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

50. 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?

51. 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

52. 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)

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

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

55. 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

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

57. 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

58. Yairi & Ambrose (2005)

59. 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

60. 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

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

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

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

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

65. 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.

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

67. 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.

68. 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

69. 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%

70. 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

71. 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

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

73. 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

74. 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

75. Making a functional link (original located on website)

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

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

78. 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