Fluency Mid-term Test - Part Three - Assessments

Framework for Assessment, Diagnosis & Treatment

ABCs of stuttering 

Affective 

• Emotional makeup of child & their responses 

Behavioural 

• What child does/doesn’t do 

• What others do/don’t do in response to stuttering 

Cognitive 

• Thoughts & attitudes about stuttering & communication

Assment in preschoolers

• Obtaining info from caregivers 

• Case history/intake form 

• Caregiver interview 

• Caregiver report instruments

Why do you need to do a case history with preschoolers

• informs of personal knowledge & experience with stuttering 

• facilitates consideration of risk factors for stuttering persistence

What should be included in a preschooler's case history?

A. personal & family information

• parents & stuttering history 

• siblings & stuttering history 

• stuttering history of other relatives 

• languages at home

B. time & circumstances at onset 

• When was stuttering first noticed? 

• Onset sudden or gradual? 

• Contributing health & emotional factors?

C. symptomatology at onset & present 

D. general child development & health

• questions about motor development, behavioural problems, … 

• co-existing difficulties may influence intervention planning

Caregiver interview

• After observation but before more comprehensive formal Ax procedures 

• How can we help you & your child today? 

• What do you most want to learn from this Ax? 

• What are your best hopes for your child?

Caregiver report instruments

• Impact of Stuttering on Preschool Children & Parents (ISPP) 

• Palin Parent Rating Scales (Palin PRS) 

• Vanderbilt Responses to Your Child’s Speech (VRYCS) 

• Test of Childhood Stuttering – Observational Rating Scales (TOCS ORS) 

• Fluency 

• Consequences

Assessments - Observing & testing preschoolers

• Look at, listen to & learn about 

• Start by observing play & talk with whānau (& siblings)

1. Speech samples 

2. Secondary characteristics 

3. Awareness & emotional reactions 

4. Anxiety, temperament & personality 

5. Language, phonology, motor & hearing skills 

6. Overall diagnosis & severity

Observing & testing preschoolers -  Speech samples

• need quantifiable data 

• need audiovisual recordings 

• stuttering fluctuates!! 

• at least 2 samples in clinic on different days + 1 at home 

• in clinic need > 500, preferably 1000 syllables 

• 2 recording sessions, 2 separate days, 15-20mins each

• long samples necessary to observe low frequency disfluency types 

• prolongations, blocks, complex disfluencies 

• elicit speech with quiet toys 

• ask parents about topics that excite child 

• avoid yes/no questions, rather open-end

• not only total number of disfluencies 

• type of disfluency & length of disfluency important for diagnosis, prognosis & monitoring over time 

• -> time-intensive but valuable

• -> see also TOCS ORS – fluency

Observing & testing preschoolers - Secondary characteristics

• head turn, lip pursing, eye blinking, … observed in 75% of children near onset 

• complete checklist of behaviours 

• assign severity rating of secondary behaviours

Observing & testing preschoolers - Awareness & emotional reactions

• parental report 

• direct questioning 

• reinforce how much child knows about speech 

• model that stuttering is something that can be discussed clearly & openly 

• puppet test

• Questionnaire – KiddyCAT 

• assess communication attitudes of CWS 

• 12 yes/no questions in play environment 

• ‘Do you think that Mom and Dad like the way you talk?’ 

• high scores = negative attitude about speech

KiddyCAT

The KiddyCAT (Communication Attitude Test for Preschool and Kindergarten Children who Stutter) is an assessment tool that measures a young child's attitude toward communication, particularly their feelings about speech difficulties. It is used for children aged three to six years to gauge their perception of their own speech, identifying negative attitudes which can impact their willingness to communicate. Research shows that children who stutter, even at a young age, often report more negative attitudes about speech than their non-stuttering peers, making the KiddyCAT valuable for early detection and intervention planning.

Observing & testing preschoolers - Awareness & emotional reactions

• Questionnaire – Impact of Stuttering on Preschoolers and Parents (ISPP) 

• indirect approach, parent questionnaire 

• 20 questions about child, playmates & parents

ISPP

ISPP, or the Impact of Stuttering on Preschoolers and Parents questionnaire, is a tool used to assess the subjective experience of stuttering by measuring how a child's stuttering affects their daily life, including their feelings, reactions, and behaviors. It provides a comprehensive, multi-dimensional view of stuttering's impact, which can help direct treatment by identifying specific areas for intervention and evaluate the effectiveness of therapy over time. The questionnaire includes information on the parent's experience, family reactions, parent-child interaction, and the child's communication and reactions to stuttering.

Observing & testing preschoolers - Anxiety, temperament & personality

• Short Behavioral Inhibition Scale (SBIS) 

• Children’s Behavior Questionnaire, Very Short Form (CBQ - VSF)

Observing & testing preschoolers - Language, phonology, motor & hearing skills

• may help decisions on initiating therapy & selecting approach 

• e.g., CELF Preschool-3

Observing & testing preschoolers - Overall diagnosis & severity Scales

most children can be characterised as presenting with 

• age-appropriate fluency skills 

• stuttering 

• stuttering with a concomitant speech/language disorder

• Severity rating – perceptual scale 

• Yairi: 8-point scale 

• Lidcombe: 10-point scale

• 9 is extremely severe stuttering – this would mean that the stuttering is so severe that the person almost can’t utter any words and has lots of secondary behaviours

Observing & testing preschoolers - Overall diagnosis & severity

• Severity rating – formal instruments 

• Test of Childhood Stuttering (TOCS) 

• 4-12 years 

• identify children who stutter 

• determine severity of stuttering 

• document changes in fluency over time

• Severity rating – formal instruments 

• Stuttering Severity Instrument (SSI-4) 

• > 2 years 

• Frequency 

• Duration 

• Physical concomitants

Prognosis in preschoolers (<6yo)

Concluding parent conference

• Outline main characteristics of child’s stuttering 

• Discuss possible future course

• Give advice about 

• stuttering treatment 

• home environment 

• listener’s responses

• Advice - home environment 

• Decrease various pressures 

• Decrease emotional and physical excitement 

• More relaxed, slow-paced activities 

• Speak slower, especially to child 

• Promote childʼs self confidence

• Advice – handling stuttering 

• Listen patiently as child stutters 

• Repeat childʼs stuttered word: easily and stretched a bit 

• Reinforce fluency: “this was easy” 

• Show empathy: “Sometimes speech is difficult”

Risk Factors

• Known family history of (any) stuttering

• Male sex

• Older age at onset (>3.5 years)

• Higher rate of SLD

• Lower receptive language

• Lower speech sound skills

• Lower expressive language

• stuttering for >1 year 

• stuttering trajectory 

• increase over time, no decrease, or decrease plateau 

• emotional reactivity 

• more excitable

Assessment of school age children - general considerations

• Parental concern about stuttering reliable indicator of presence of stuttering in children 

• Little justification for ‘wait-and-see’ 

• Increase in secondary behaviours, coping & concealment strategies with increased selfawareness of stuttered speech 

• Significant percentage have concomitant speech sound production, expressive or receptive language difficulties

• Multidimensionality 

• Not only speech but comprehensive assessment necessary 

• e.g., OASES & CALMS 

• Variability 

• Within International Classification of Functioning, Disability and Health (ICF) framework

Background & Case history

• Stuttering history 

• Treatment history 

• Current speech description 

• Environmental influences on speech 

• Stuttering impact on QOL 

• Other relevant case history 

• Client’s perspective

Background & Case history - School-age children

• Interview with parent 

• Interview with child 

Tell me about some things you are good at? 

• Do you like talking? 

• Do you participate in class discussions? Answer questions? 

• Do other children make fun of your stuttering?

• Use alternate wording if diagnosis uncertain, e.g., repeating a word, getting stuck when talking 

• Due to anxiety, shame etc. children may downplay stuttering severity & impact on QOL

Background & Case history - Adolescents & adults

• Focus on overt stuttering behaviors often secondary in Ax & Tx 

• Provide info about stuttering & Tx 

• Unlikely to completely recover, will experience at least some amount of stuttering for the rest of their lives, regardless of therapy 

• Manage expectations: controlled fluency, less effortful stuttering or managed stuttering

Observations & Examinations  - school aged and adults

1. Speech examination 

2. Situation Rating Scales 

3. Emotions & Attitudes Rating Scales 

4. Tests for overall stuttering severity
   

a. Speech examination 

2, ideally 3 separate speech contexts 

• conversation or monologue 

• reading 

• speaking context relevant for individual 
  

• obtain speech sample with full extent of severity 

• comparison to normative dataset?

Sample size for speech examination for school-aged kids and adults

Conversation/monologue 

• > 300 syllables 

• > 600 syllables better to identify blocks & longer repetitions 

Oral reading 

• ~ 200 syllables

Disfluency Measures

Stuttering frequency 

• more than 1 stuttering instance per word/syllable possible 

Percent syllables stuttered 

• only one stuttering instance per syllable possible 

• 1.5/1 syllables-to-words ratio in adults, 1.15/1 in children 

• Count syllables that would be spoken had there been no disfluent speech 

Audiovisual samples preferable

Stuttering Severity

based on speech characteristics 

• how often is speech disrupted 

• how long is speech disrupted 

• secondary behaviours associated with disruptions 

• Tools: SSI-4, 8-point rating scale, 10-point rating scale, … 

• may not reflect impact of total stuttering disorder

Speaking effort increases as children age

Physical effort 

• extraneous movements, excessive physical tension, atypical speech breathing, atypical phonation during speech etc. 

Mental effort 

• increased awareness of stuttering 

• linked with increase in responses to stuttering with selfdevised stuttering management strategies that require substantial mental effort to implement 

• e.g., word substitution, avoidance, stalling

Situation rating scales

• Become more important with longer stuttering experience 

• To collect info on variability of stuttering across situations & contexts 

• -> Case history information 

• -> Specific instruments

Instruments 

• Speech Situation Checklist 

• Individualized Situation Hierarchy 

• Rapport necessary

 Emotions & Attitudes Rating Scales

• Consider attitudes about stuttering, speaking, self, other people, … 

• Can be challenging 

• Be respectful & sensitive

Instruments 

• Individualised interview about emotions & attitudes 

• Overall Assessment of the Speaker’s Experience of Stuttering (OASES) 

• Unhelpful Thoughts and Beliefs About Stuttering (UTBAS) 

• Modified Erickson Scale (S-24) 

• Perceptions of Stuttering Inventory (PSI) 

• Locus of Control of Behavior Scale (LCB)

Emotions & Attitudes Rating Scales - Specific instruments – for children 6+

• Behaviour Assessment Battery for School-Age Children Who Stutter (BAB) 

• -> Communication Attitude Test (CAT) 

• -> Speech Situation Checklist (SSC) 

• -> Behavior Checklist (BCL)

Tests for overall severity

• Stuttering severity instrument (SSI-4) 

• ->  Riley, 2008  - norms from other stuttering children so that you can determine the severity of stuttering 

• Test of Childhood Stuttering (TOCS) 

• -> Gillam et al, 2009

Interpretations & Recommendations

Differential diagnosis? 

• Rare instances of feigned stuttering 

Differences across clients 

• very mild stuttering but high impact 

• lots of avoidance 

• lots of tension in articulators 

• lots of secondary characteristics

Assessment tools

• Stuttering Severity Instrument (SSI) 

• Test of Childhood Stuttering (TOCS) 

• SSC-SD: Speech Situation Checklist Speech Disruption 

• CAT: Communication Attitude Test 

• BCL: Behavior Checklist 

• KiddyCAT

• CALMS

• Questionnaires for Adults

Questionnaires for Children

• Cognitive, Affective, Linguistic, Motor & Social components related to stuttering (CALMS) 

• Behavior Assessment Battery for school-age children who stutter (BAB-S) 

• SSC-ER: Speech situation Checklist Emotional Reaction 

• SSC-SD: Speech Situation Checklist Speech Disruption 

• CAT: Communication Attitude Test 

• BCL: Behavior Checklist 

• KiddyCAT

• CALMS

Questionnaires for adults

• OASES: Overall Assessment of the Speaker's Experience of Stuttering (Yaruss & Quesal, 2006) 

• BAB-A: Behaviour Assessment Battery for Adults (Vanryckeghem & Brutten, 2018) 

• UTBAS: Unhelpful Thoughts and Beliefs about Stuttering (Australian Stuttering Research Centre, 2020) 

• PSI: The Perceptions of Stuttering Inventory 

• Erickson S-24: Attitudes to Communication Scale (Erickson,1969) 

• RET: Rational Emotive Behaviour Therapy 

• -> Oxford University Press; DiGiuseppe, Doyle, Dryden and Backx, 2013 

• FNE: Fear of Negative Evaluation scale 

• LCB: Locus of control of behavioural scale 

•  EMAS-T: The Endler Multidimensional Anxiety Scales–Trait

OASES - The Overall Assessment of the Speaker's Experience of Stuttering

The Overall Assessment of the Speaker's Experience of Stuttering (OASES) is a self-report questionnaire that comprehensively measures a person's experience of stuttering, including their emotional and cognitive reactions, functional communication difficulties, and the overall impact on their quality of life. Unlike traditional fluency measures, the OASES focuses on the individual's perspective of stuttering and can be used before and after treatment to assess therapy outcomes based on personal goals. 

BAB-A: SSC-ER - Behavior Assessment Battery The Speech Situation Checklist-Emotional Reaction

The Speech Situation Checklist-Emotional Reaction (SSC-ER) is a sub-test of the Behavior Assessment Battery (BAB) for people who stutter, assessing their anxiety, fear, and worry in specific speaking situations. It helps identify the speaker's negative emotional responses,  The SSC-ER provides a self-report "inside view" of a child's or adult's affective reaction to stuttering, which aids clinicians in shaping targeted therapy and understanding the full impact of stuttering beyond observable disfluencies. 

CAT - Communication Attitude Test

The Communication Attitude Test (CAT) is a questionnaire used by speech-language pathologists to measure a child's attitudes and beliefs about their own speech, particularly in children who stutter. It provides a self-report measure of a child's emotional reactions, avoidance behaviors, and thoughts concerning their speech, which helps clinicians understand the multifaceted impact of stuttering on the child's communication and develop personalized treatment plans. The CAT has different versions, such as the Kitty CAT for preschool children and a version for older children, and its responses are often scored to indicate the presence of negative attitudes toward their communication. 

BAB-A: SSC-SD - Behavior Assessment Battery Speech Disruption

The BAB-A is the Behavior Assessment Battery, an evidence-based battery of self-report tests for assessing school-aged children (ages 6-15) who stutter. The "SSC-SD" within the BAB-A refers to the Speech Situation Checklist - Speech Disruption subtest, which specifically measures the amount of speech disruption, or stuttering, a child experiences in various speech situations on a 5-point scale. It evaluates the degree of stuttering in different speaking contexts. It asks a child to rate their level of speech disruption in 55 different speech situations.Scores range from "no trouble" to "very much trouble" talking.

BAB-A: BCL - The Behavior Assessment Battery Behavior Checklist

The Behavior Assessment Battery (BAB) is a set of self-report tests that evaluate the Affective, Behavioral, and Cognitive (ABC) dimensions of stuttering in children and adults. The Behavior Checklist (BCL) is one of the core components of the BAB, and it serves to inventory the number, type, and frequency of avoidance and escape behaviors a person uses in response to the anticipation or occurrence of stuttering. The BAB provides a comprehensive view of how a child or adult feels, reacts to, and thinks about their speech. The BCL, as part of the BAB, helps a speech-language pathologist identify a person's avoidance and escape behaviors related to stuttering, providing valuable information for developing a targeted and effective intervention plan to address these patterns.

BAB-A: BigCAT - Behavior Assessment Battery Communication Attitude Test

The Behavior Assessment Battery (BAB), which includes the BigCAT (Communication Attitude Test), is a multi-component, self-report assessment for children and adults who stutter, designed to evaluate their affective, behavioral, and cognitive (ABC) reactions to their stuttering. The BigCAT specifically measures a speaker's speech-associated attitude, assessing how they think and feel about their communication.

UTBAS - Unhelpful Thoughts and Beliefs about Stuttering

The Unhelpful Thoughts and Beliefs about Stuttering (UTBAS) is a self-report measure designed to assess unhelpful cognitions (thoughts, beliefs, and associated anxiety) in people who stutter, particularly in relation to social anxiety. The full scale has 66 items across three sections: frequency of negative thoughts, belief in those thoughts, and the anxiety associated with them. A brief, 6-item version (UTBAS-6) was developed for efficient screening, providing a reliable way to determine if referral for a psychological assessment is warranted based on high scores. The UTBAS is a valuable clinical tool to identify negative cognitions that can affect treatment outcomes and overall functioning.

PSI - Perceptions of Stuttering Inventory

The Perceptions of Stuttering Inventory (PSI) is a self-report tool developed by Woolf (1967) that assesses a person's subjective experience of stuttering through its impact on behavior and thoughts, specifically focusing on three dimensions: struggle, avoidance, and expectancy. The PSI measures the extent of physical and verbal efforts during speech, efforts to avoid stuttering-inducing situations or words, and anticipatory anxiety about future stuttering, providing a more comprehensive view of a person's communication experience beyond just the physical aspects of stuttering.

Erickson S-24

The Erickson S-24 is a 24-item true-false questionnaire that assesses an individual's communication attitude, particularly their perceptions and beliefs about stuttering. Higher scores on the S-24 indicate more negative attitudes and greater fear of communication situations, while lower scores suggest more positive attitudes and reduced avoidance behaviors. This tool is used with adults and older adolescents who stutter to provide a quantifiable measure of their subjective experience and complement objective behavioral assessments of stuttering.

RET - Rational Emotive Behavior Therapy

A stuttering assessment incorporating Rational Emotive Behavior Therapy (REBT) aims to identify and restructure the irrational beliefs that lead to tense speech and avoidance behaviors in individuals who stutter. The assessment process involves understanding the client's worldview and their self-concept, then applying the REBT ABCDE model to pinpoint activating events (A), irrational beliefs (B), and their emotional and behavioral consequences (C). The goal is to dispute (D) these irrational beliefs and replace them with rational ones (E), thereby reducing stuttering tension and avoidance and improving overall speech and life satisfaction.

FNE - fear of negative evaluation

A fear of negative evaluation (FNE) stuttering assessment measures a person who stutters' (PWS) intense worry about being negatively judged by others, often leading to avoidance behaviors and contributing to social anxiety and the negative impact of stuttering. The Brief Fear of Negative Evaluation Scale (BFNE-S) is a common tool used to assess FNE by having participants rate how characteristic specific negative social situations are of them. A comprehensive assessment for PWS should include FNE as it helps clinicians understand the affective, behavioral, and cognitive aspects of stuttering, guiding therapy to reduce negative thoughts and improve coping skills, according to the American Speech-Language-Hearing Association (ASHA).

LCB - The Locus of Control of Behavior

The Locus of Control of Behavior (LCB) scale is a self-assessment tool used in stuttering therapy that measures a person's perception of control over their speaking behavior, rather than directly measuring fluency. It helps assess and track changes in a person's attitude towards their stuttering, their confidence in managing it, and their reactions to communication challenges, especially regarding quality of life and self-evaluation after therapy.

EMAS-T - Endler Multidimensional Anxiety Scales–Trait

The Endler Multidimensional Anxiety Scales–Trait (EMAS-T) is a self-report measure assessing general, long-term anxiety in individuals, including those who stutter. It differentiates anxiety into multidimensional constructs, identifying cognitive and autonomic components. While the original EMAS was developed for general anxiety, its trait form (EMAS-T) can be used with stuttering clients to assess the underlying, pervasive anxiety they may experience, particularly with the expectation of social harm, which is a significant psychosocial aspect of stuttering.

SSI-4 - Stuttering Severity Instrument—Fourth Edition

The SSI-4 (Stuttering Severity Instrument—Fourth Edition) is a norm-referenced assessment that provides a standardized, reliable way to measure stuttering severity in children and adults. It quantifies severity by evaluating four key aspects of speech: the frequency of stuttered syllables, the duration of stuttering blocks, the presence of physical concomitants (secondary behaviors), and the overall naturalness of the individual's speech. The SSI-4 includes tasks for readers and non-readers, such as reading grade-level passages or describing pictures, and can be used for both clinical evaluation and research purposes.

TOCS - The Test of Childhood Stuttering

The Test of Childhood Stuttering (TOCS) is a multi-component assessment tool that identifies children who stutter, determines their stuttering severity, and documents changes in fluency over time. It includes a Standardized Speech Fluency Measure with tasks like rapid picture naming and structured conversation, Observational Rating Scales to gather parent and teacher input, and a Supplemental Clinical Assessment to provide detailed data on disfluency. The TOCS provides a comprehensive understanding of a child's fluency across different speaking contexts

CALMS - Cognitive, Affective, Linguistic, Motor, and Social

The CALMS stuttering assessment is a multidimensional model that evaluates stuttering in five interconnected components: Cognitive, Affective, Linguistic, Motor, and Social. Developed for school-aged children, the assessment uses a rating scale to score each component from 1 (low impact/concern) to 5 (high impact/concern), with scores derived from clinical tests and observations to create a profile of the child's strengths and needs in relation to stuttering. The goal is to identify how each component influences the child's communication and to inform treatment plans that address these varying demands, rather than focusing solely on traditional fluency metrics.