Diagnostic Concerns in Fluency Disorders

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Diagnostic concerns in fluency

disorders


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Fluency Assessment

DataCollection

Analysis &Interpretation

Information &Counseling


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Assessment Overview

Fluency Assessment

Plan for

Data Collection

Determine Goalsof Evaluation

Determine InformationNeeded

Select AssessmentTools

Generate

Dx Questions

Consider Resources

for Information

Client

FamilyTeachers

Objective

Measures

Interviews

Questionnaires

Self-Evaluations

Speech Samples:

Speech &Nonspeech Behaviors

Formal

Tests

Attitudes

Perceptions

Avoidance BehaviorHistory


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The goals of a fluency

evaluation

For young children: Do they stutter?

Developmental stuttering vs. normal disfluency vs. language formulationdisfluency

If they stutter, how likely is recovery? examination of risk factors

What is the appropriate next step? Monitoring, parental consultation Indirect management Direct management

For older children and adults: How significant is the stuttering problem?

In terms of overt symptoms In terms of associated behaviors, including frustration, fear, avoidance, and

perceptions of handicap and disability What factors affect fluency and associated affective and emotional states? What are the goals of fluency therapy?


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Appraising overt symptoms: the

speech sample

From children: Conversation with you and with the parents Narrative (e.g., Frog stories) Recreation of situations/contexts in which fluency is

reported to wax and wane

From adults: Monologue (may be done during case history)

Conversational interaction Reading Optional: appraise consistency and adaptation using

repeated reading of materials


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Tallying disfluencies (overt behaviors)

from the speech sample What gets counted?

Normal disfluencies

Stutter-like disfluencies (SLDs)

Calculating proportions what are your numerators and denominators?

Appraising frequency Via percent stuttered words or syllables

Problems with purely time-based measures

Describing typology What are the proportional incidences of major disfluency subtypes?

Reliability of behavioral measurements Tom exercise


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Examining accessory features

A tip: listen to the tape without looking,then look without listening

Things to look for: Atypical speech production postures Ancillary body movements

Eye gaze Sample assessment instruments: SSI-

3, Cooper Scales


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Attitude assessment

Potential

measures:

See samplehandouts

How does stuttering affect

the individuals everyday

behavior?

What are perceptions ofdisability and handicap?

How do they feel about

speaking and stuttering?

What do they know or

believe about their

stuttering?


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Goals of the assessment

For parents, what are the goals? Can

they supply more than one? Using goals to explore options

What are the clients goals?


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Dx summary

preschool children

Questions that need tobe answered: Is it stuttering? What is the likelihood of

spontaneous recovery? What has been done up

to now, with what

results? What are the pros and

cons of varioustreatment models?


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Preschoolers (continued)

Information required: Frequency, duration and types of disfluency Presence of struggle or tension

Presence of awareness and reactions tomoments of disfluency Assessment scales (see handouts)

Status of other speech/language abilities Parent-child communicative style Parents reactions and attitudes toward behaviors Parents understanding of the nature of stuttering Perceived risk factors for chronicity or worsening

of symptoms


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Preschoolers (continued)

Case history specifics: Parents information about onset, course of

disfluency patterns over time

Medical, social and developmental history Child and listener responses to disfluency Level of awareness, frustration, avoidance, self-

consciousness Reactions of others in the childs environment,

including advisements

Parents beliefs about cause of the problem Parents views of the childs personality and

temperament Family history of stuttering and other

communicative disorders


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Behavioral measures for pre-

schoolers: What are SLDs?

Stutter-like disfluencies include: Sound, syllable and monosyllabic whole word

repetitions

Weighted scores for disfluency take into account thenumber of iterations

Blocks, prolongations, broken words

Other disfluencies might include:

Interjections, filled pauses Revisions Multisyllabic word or phrase repetitions Hesitations


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Step Two: Assess predictors

of remission and chronicity

The facts: ~80% of children who begin to stutter will

recover (apparently without clinicalintervention) The time frame for remission may be more

limited than previously supposed (Yairi, et al.,

1996; Ramig, 1993)


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Predictors of chronicity andremission*

Gender

Time

since

onset

Family hx ofpersistence &

recovery

Age at

onset

Speech&language

skills

SLD's over12 mos.

post-onset

*from Yairi, Ambrose, Paden & Throneburg (1996),

JCommDis, 29, 51-77.


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Weighing the oddsMore

concern

Less

concern

Family history of chronic stuttering

Male

Stable or increasing pattern of Stutter-Like

Disfluencies (SLD's) over 12 mos.Stuttering onset after 36 months

Relatively poorer speech/language performance

No family history or history of

recovered stuttering

Female

Decrease in SLD's over 12 months

Early onset of symptoms

Strong speech/language skills


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Patterns to monitor

0

2

4

6

8

10

12

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January April July Oc tober January April July Oct ober January

Recovery Chronic Immediate concern


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Watch and see, not wait and see

As in SLI, the rapid course of

remission, but uncertain future of

individual children requires thepartnership of parents and clinician to

actively monitor progress and

establish guidelines for implementingintervention (Paul, 2000)


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Dx summary: school-aged

children

Questions that need to be answered: How complex has problem become? (awareness, shame, guilt, self-image

as a CWS?)

Is any part of problem language-based?

What are relative contributions of physiological factors, psychologicalfactors, attitudes and learning?

What is childs perception of problem? How does it compare to the

parents perceptions?

What intervention strategies would be most beneficial?

In what capacities will parents/school be involved? Educational component

Coordination of services


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School-aged children

(continued)

Information required: Medical, developmental, social and educational history

Full understanding of speech/language abilities

Frequency, duration, concomitant behaviors Impact on emotional development

Parental/family/school reactions and attitudes toward

stuttering

Child and parents understanding of the nature of

stuttering

Previous speech therapy: approaches and outcomes

Listener reactions and responses to listener reactions


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The CALMS Model of Stuttering

(Healey, et al., 2001)

Affective - feelings, emotions, attitudes

Linguistic- language

skills, lang.

formulation

demands &

discourse

Cognitive- thoughts

- perceptions

- awareness

- understanding

Social - effects oftype of listener & sp. situation

Motor- Sensori-motorcontrol of speech movements

A E l f H th CALMS


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An Example of How the CALMS

Factors

Interact During a Speaking Situation

Motor- I wonder if myfluency targets will work? My

tongue and voice feel tense.

Social - I really dont want to talk withthis person. I feel pressure to talk in this

situation.

Cognitive- I hope I dont stutter.- Im not a good talker.

- I want to avoid talking

- People will laugh at me.

Affective- I feel embarrassed, Im confused,Im afraid, I hate my stuttering.

Linguistic- What am I goingto say? How will

I say this and

be fluent?


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School-aged children

(continued)

Parent interview: similar to that of preschoolers;adjust to be age-appropriate

Teacher interview General questions about achievement and social

development How does stuttering affect these areas? Reactions of students and staff to stuttering?

Childs reaction? Level of participation, verbally and nonverbally in

classroom and other school activities Information about services received at school


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Tips for interviewing young

children

Some basics: Dont be alarmed if child says, I dont

know or shrugs shoulders. Children arenot used to evaluating feelings. They dont

necessarily evade. Some children just

accept things the way they are.

Share something about yourself, and the

type of work you do: One of my jobs is to help kids talk better


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Talking to young children

(continued)

Use analogies and examples to help the child feel

comfortable talking about problems.

For example, One of my friends who comes to play with me is Josh.

He sometimes gets stuck when the teacher asks him to read to the

class. Does that ever happen to you? Use a marble maze with some marbles too large to flow freely. Have

some get stuck. Then say, This marble is s-s-s-stuck. That picture

on the wall was made by Josh. It shows how he crunches up his

face when he gets stuck. What kinds of things do you do?


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Some questions to ask young

children

Whom do you like to talk to? (At home, at school) Who talks the most/least (At home, at school) Who interrupts? Who do you interrupt?

Who are good talkers? When do you want to talk well?

Are there times you want to talk extra well? Do other people feel this way as well?

When do you want to talk more than you do? Who listens/pays attention? What do you like listeners to do when you talk to

them?


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Qualifying children for services

in the schools

Please see diagnostic considerations

for qualifying CWS under IDEA and

writing IEPs (separate handout).


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Dx summary - Adults

Questions you need to answer: What type of fluency disorder is it?

Developmental stuttering Cluttering Neurogenic stuttering Psychogenic stuttering

If developmental stuttering, what are the relativecontributions of physiological, psychological, attitudinalfactors and learning?

Why does the client seek tx now? goals?

How does disfluency affect clients communication and life? What intervention strategies will be most appropriate?


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Adults (continued)

What information will be needed? Disfluency types

Severity of the disorder

Percentage of disfluencies Concomitant behaviors

Fears and avoidances

Clients attitude toward disorder

Core and secondary behaviors Emotional reactions/attitudes

Social, vocational and lifestyle information


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Adults (continued)

Interview specifics: Onset and early development; how was stuttering handled in

family? What does client believe caused it?

Impact educationally, socially and vocationally

Outlook: hope for change, past tx experiences, motivation to

change

Patterns of recovery and relapse, situational variability

Family history

Level of fear of speaking and stuttering Avoidance patterns

Self-perceptions


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Adults (continued)

Measuring impairment, disability and

handicap (Yaruss & Quesal)

Speakers reaction to stuttering Functional communication

Quality of life


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Measuring speaker reactions:

tools

Watson (1998) Inventory ofcommunication attitudes

Ornstein & Manning (1985) Self-Efficacy Scale (SEA-Scale) for Adultswho Stutter

Andrews & Cutler (1974) adaptationof Ericksons S-Scale

Yaruss & Quesal (2000)


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Diagnostic interpretation

For children Provide data on prognostic indicators, and work

with parents to determine next steps, which

should include a minimum of active monitoringand counseling to palliate symptoms.

Introduce information about therapy approaches

Provide information and information sources to

help family explore stuttering.


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For adults: Explain the therapy approaches that you

offer, and explore acceptability to client.Is this what the client had in mind?

Negotiate the terms of therapy

Help them become informed consumers;provide information sources.

Diagnostic Concerns in Fluency Disorders

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