Intro to Assessment (copy)

Definition of Diagnosis

the identification of a specific condition usually not apparent at the beginning

Differential diagnosis

discerning the nature of a disorder as different from other possible clinical entities

Differentiate possible subtypes of the fluency disorder (psychogenic, acquired, malingering?)

Differential Diagnosis – Examples

• stuttering vs normal disfluencies

• early stuttering vs advanced stuttering

• stuttering that will recover vs stuttering that will persist

• Stuttering vs. Cluttering

• Stuttering (Developmental) vs. Neurogenic Stuttering

Stuttering vs. Normal Disfluencies

Does this person exhibit more SLD than OD?

Early stuttering vs. Advanced Stuttering

Early stuttering is language based disfluencies whereas advanced stuttering is when patterns have been established and they are presenting with blocks and secondary characteristics

Is this child exhibiting more language based disfluencies or are there already characteristics of more advanced stuttering?

True/False? Stuttering and cluttering can co-occur

True

Stuttering (Developmental) vs. Neurogenic Stuttering

Is this more characteristic of developmental stuttering or did this stuttering occur as a result of some neurological insult?

Why are we talking about adults, teens and school age children?

• Many assessment items overlap for adults, teens and school age children

• When you work with an adult, you will likely only be interviewing/assessing the adult in the room

• Teen – a teen can answer many of the questions like an adult without help minus the case history questions as they may not know their developmental hx

• Older school age child – asking about their parents immediate reactions to stuttering may be more relevant than teen or adult

When does your assessment begin?

Starts the moment they enter with an informal observation

What areas are you observing during an informal observation?

• observations of posture

• social skills

• the way in which a person speaks

• the way in which a person stutters 

Purpose of assessments? (assessment objectives)

• establish rapport

• obtain background/case history

• describe speech characteristics

• consider home/social/work environments

• understand the impact on client's life

• provide information about stuttering

• recommend a plan of action

Obtain background/case history

• You need an organized record of this information.

• “What do you do when you stutter?” (do they answer with emotion or the speech characteristics?)

Important questions to ask the client

• what do you do when you stutter?

• what are your expectations for therapy

what are your expectations for therapy?

Ask this up front!

• Do they want a prescribed tx? Exercises? Hypnosis?

• Do they understand they will have to work diligently to see change and that they will often have to do what they dislike doing most and are uncomfortable with?..

What's the goal of therapy for PWS?

The goal is not fix the stutter but to provide skills to deal effectively with the stutter and improve communication skills overall

KEY to remember with adults/teens/older school age

Often the emotional reaction to stuttering is more severe than the stuttering behavior itself

Information gathered during case history

• stuttering / family history

• treatment history

• current speech description

• environmental variables affecting speech

• impact of stuttering on quality of life

• other relevant case history

• patient's perspective

• identifying information

What kind of questions should you ask a child during interview?

• subjects they like/dont like

• after school activities

• what they do well

• do they like talking and where, when, with who

• peer's response/teacher's response

What should you be asking the parents?

• does stutter affect child in school

• stutter different at school vs. home

• describe child's typical day

• describe speech

• is socializing affected

• any other impacts

• is fluency important to child

After obtaining the case history and interview, what comes next?

speech sample

In what context can you collect a speech sample?

• conversation (more turn taking in conversation)

• monologue (not as common, faster to reach word count you need)

• reading

monologue

• Clinician directs the patient to talk for 3 minutes about a current job or vocation, future jobs or those held in the past – why he or she chose that job

• Patient is given one minute to prepare and then starts talking – if they don’t talk for 3 min then the clinician asks them follow up questions

• You as the clinician should notice if they get more fluent as they go along talking (adaptation for continued talking, means they may exhibit more mild stuttering/more alterable stuttering

Due to the variability of stuttering, you should choose at least _________ to examine a speech sample and try to get to _____ at least!

2 different contexts; 300 words

Consider having shorter vs. more complex utterances at hand

do longer more complex sentences increase disfluencies

other options for speech samples

• Automatic picture naming

• Imitation

not as meaningful :/

outside samples

• Preschoolers: at home

• School-age: in school

• Adolescents and adults: at work or in a phone conversation

what is important for major samples, if you have the ability, so that you may evaluate secondaries later you may miss?

videotaping

For major assessments, try to get  how many syllables/words for conversation? for reading?

300-400 for conversation; 200 for reading

If you are providing a reading sample, should the passage be above their level?

No, must be at or below their current reading level

more complex = more disfluencies

After speech/language sample collection, determine:

behaviors of interest:

Examples: Disfluency types? Stuttering events? Fluent words?

Units to be analyzed:

Syllables? Words? - many use words!

Strengths to be looking for in PWS

• do they look at you when they are talking

• turn take well in conversation?

• body posture

• gesturing

Severity refers to the level of what?

disruption in the delivery of continuous speech

Severity may not correspond to what?

the impact or experience of the disorder

Stuttering can be ____, but cause minimal concern or social impact

severe

Stuttering can be ___, but cause deep concern and negative social impact

mild

in order to be considered secondary characteristics…

movements HAVE to be associated with the person's talking and stuttering

example: Some people who do not stutter close their eyes or blink frequently when talking

Is it considered a secondary characteristic if a movement occurs while a person is NOT stuttering

No, must occur during stuttering moment

Are impulsive jerking or movements, such as tics associated with Tourettes syndrome, differentiated from stuttering or not?

they are different because they are present when the person is not speaking

Escape behaviors

They are an attempt to stop the stutter during the moment of stuttering and produce a word (e.g., head nod, eye blink). occur AFTER the stutter has started

Avoidance Behavior

Attempt to avoid the stutter BEFORE it has happened. (ex. saying an extra sound, changing the word)

Severity assessments often include measure of what?

secondary behaviors

With adults, teens and older school age children we are concerned with the:

• emotional state

• behaviors and attitudes

• stuttering severity

• paying attention to the presence of how the disfluencies (SLD) impact their ability to communicate and function in society.

Situational Rating Protocols

• Be aware of your patient’s emotional state and if they are ready to fill one of these out.

• Patients may fill this out with answers they think you want to read if they are not ready to be honest about their answers…

• You may re-do these as part of your progress monitoring (encouraged) with the patient, these can be a good indicator that your patient is making progress with their emotional state etc., while they still exhibit stuttering that may not have improved significantly