CC7 - Fluency - Chapter 10 (Assessment of Preschool Children Who Stutter) & Chapter 11 (Assessment of School Age Children, Adolescents, and Adults Who Stutter)

Clinical Questions

• Stuttering or normal disfluency?

• If stuttering, what are the disfluencies like in various situations, and how does it change over time?

• What are the child’s responses? Emotions?

• What are the family’s concerns, expectations, etc.?

• Treatment options—none, waiting, indirect, direct?

• Language, articulation, and voice age appropriate?

• Any issues for which referral needed?

Initial Contact

• Usually on telephone

• Listen carefully and respond to level of concern

• Make appointment as appropriate

• Provide suggestions to give parents useful ways to start helping child

Video Recording

• Helpful to get video of child speaking spontaneously at home

• Five to ten minutes of parents playing with child is usually adequate, unless stuttering is highly variable, in which case, more than one sample may be needed

• Provides important sampling of stuttering that may be worse at home than at clinic

• Parents can leave camera on stand for several days to get child used to it before filming

Parent-Child Interaction

• Done first to get unbiased sample

• Opportunity to observe child’s stuttering and awareness of it

• Opportunity to observe parent’s style of interacting with child

• What are key elements to observe?

• Video record for later analysis

Parent Interview #1

• Interview with child present or not—what are the pros and cons of each?

• Begin with open-ended questions about what parents’ concerns are

• Careful, nonjudgmental listening is important

• Leave time at end of parents’ questions

• Get a sense whether parents blame themselves for the child’s stuttering. Explore this. At an appropriate time during the interview, let them know the latest scientific information about possible etiology of stuttering.

Parent Interview #2

• Gather information about

• Child’s birth and development

• Family history (stuttering and other disorders)

• Onset of stuttering and changes over time

• Child’s awareness and response to his stuttering

• Parents’ response to child’s stuttering; their ideas about the cause

• Previous treatment

• Child’s personality and environment

• Parents’ questions

Clinician-Child Interaction #1

• Opportunity to observe child’s stuttering and his response to various stimuli

• If child is quite fluent, clinician may speak rapidly and ask many questions to see if stuttering appears

• If child is stuttering, clinician may experiment with fluency facilitating interaction, such as speaking slowly

• If child is aware, discuss with parents the benefit of talking to child about stuttering.

Clinician-Child Interaction #2

• Clinician can ask child if he ever gets stuck on words or has trouble talking. Should be done very acceptingly

• Children usually relieved by open, reassuring discussion of stuttering

• If child is reluctant to talk or play with clinician, it’s important not to push; clinician can play with an appealing toy and talk to self, and eventually child may join.

Speech Sample Analysis #1

• Obtain sample from home and sample from clinic—at least 200 (300 if possible) syllables each

• General observations to make from sample:

  • Frequency of disfluency

  • Types of disfluency

  • Nature of repetitions, prolongations, and blocks

  • Starting and sustaining airflow and phonation

  • Physical concomitants • Word avoidances

Speech Sample Analysis #2

• SSI-4: Assess child’s severity (see Chapter 8)

• Speech rate: syllables per minute (see Chapter 8)

• Feelings and attitudes

  • Ask parents

  • Observe child’s reactions to his stuttering

  • Talk to child directly about his stuttering

  • Feelings and attitudes can range from being totally unaware to highly frustrated and afraid

  • May change from time to time.

Feelings and Attitudes #1

• Obtain information about the child’s feelings and attitudes from the case history, parent interview, and my own interactions with the child

• The Impact of Stuttering on Preschoolers and Parents questionnaire

• However, if the child shows signs of struggle and tension when they stutter, or if the parents indicate that the child is aware through various examples of their frustration with their stuttering, I explore with the child their feelings about getting stuck on words

Feelings and Attitudes #2

• Assessment of the feelings and attitudes can determine whether the child:

  • Is unaware of their disfluencies

  • Is occasionally aware of them and, even then, is seldom and only transiently bothered by them

  • Is aware and frustrated by them

  • Is highly aware, frustrated, and afraid of them

• In addition, the questionnaire for parents described earlier in this chapter and shown in Figure 10.3—SBIS (Ntourou et al., 2020)—can be used to learn about how sensitive the child is.

Short Behavioral Inhibition Scale

Other Speech and Language Behaviors

• Parents reports and observations of child’s speech and language may reveal other problems

• Formal tests for phonological or language problems may indicate need for treatment concurrent with or following stuttering treatment

• Compare syntax with vocabulary scores; disparity may be of concern

• Also observe speech-motor and other fine motor skills

• Hoarse voice may indicate laryngeal tension associated with stuttering.

Other Factors

• Physical development

• Cognitive development

• Social-emotional development

• Speech and language environment

Determining a Diagnosis, Prognosis, and Planning Treatment

• Typical disfluency: greater than 10 disfluencies per 100 words; multisyllable word and phrase repetitions; greater than 3 iterations in reps that are slow and regular temple; child unaware

• Borderline: more than 10 disfluencies per 100 words; part-word and whole-word repetitions; more than two iterations in many repetitions; little or no tension; minimal awareness of stuttering

• Beginning: tension and hurry in stuttering; awareness and frustration; escape behaviors; possibly some avoidance

Risk Factors for Persistent Stuttering

• Factors that may be associated with persistence of stuttering:

• Stuttering does not decrease during 12 months after onset.

• Stutterer is male.

• Relatives who have not recovered from stuttering

• Below-average nonverbal intelligence scores

• Sensitive temperament.

Risk Factors for Persistent Stuttering or Extended Treatment

Closing Interview: Recommendations and Follow-up #1

• Some information is available for closing interview: for example, home video, case history and interview, observations of child’s stuttering

• Other information will be available later for report: for example, analysis of clinic video

• Need to develop hypothesis about:

  • Child’s current developmental/treatment level

  • Important risk factors

  • Treatment approach

Closing Interview: Recommendations and Follow-up #2

• Describe positive aspects of child and parents’ response to stuttering

• Describe stuttering in appropriate, clear terms

• Discuss treatment options

• Respond to questions and implied concerns

• Possible to give family a brief description of your findings that you compose just before the closing interview (see next slide for an example)

Closing Interview: Recommendations and Follow-up #3

• It may be helpful to give family a brief description of your findings when you do the closing interview

• A full report will be sent to them in a few days, but an immediate description of findings may give them something to take away, think about, and share with others.

Recommendations: Typical Disfluency

• Give information about normal disfluency

• If parents are concerned, set up another appointment in several weeks to reevaluate if disfluency persists or worsens

• If needed, recommend changes in environment that may help all children: for example, turn-taking, careful listening, appropriate speech rates

Recommendations: Borderline or Beginning Stuttering

• Use risk factors and duration of stuttering since onset to determine if treatment should be direct or indirect

• Teach parents to use severity rating (SR) scale and have them begin to use it

• Borderline (usually younger preschool children):

  • Discuss option of indirect treatment or watchful waiting

  • Provide video Stuttering and the Preschool Child or link to videos on Stuttering Foundation website

  • Have parents share weekly results of SR scale

Recommendations: Borderline or Beginning Stuttering

• Beginning (usually older preschool children)

  • Discuss indirect versus direct treatment

  • Have parents begin to use SR scale and share with you on a weekly basis

• For both levels: answer questions and provide contact information so parents can stay in touch if needed before next appointment

Clinical Questions

• What are characteristics of student’s stuttering?

• What are student’s feelings and attitudes about speaking?

• How does it affect him at school and home?

• Is he eligible for services, according to state regulations?

Public School Considerations

• Individuals with Disabilities Education Act (IDEA) and state laws set procedures for evaluation and treatment of students who stutter

• When child is referred for stuttering, SLP makes discreet observation in classroom; confers with teacher and special education administrator

• Child’s parents are contacted, permission for an evaluation is obtained, and evaluation is carried out

• Team of SLP, teacher, special education administrator, and parents discuss treatment options

Initial Contact With Parents #1

• In school setting, call to get permission to evaluate child

• Describe how student was identified and what characteristics of student’s stuttering are

• Let parent know school’s desire to help student become a more effective communicator

• Find out if family has noticed stuttering

• Maintain a caring, accepting attitude

• Explain evaluation process

• Ask them to fill out a case history form

• Try to obtain a video from home (may be more effective to wait until SLP obtains permission from child)

Initial Contact With Parents #2

• In clinic setting, a telephone call to the family can let them know what to expect in the evaluation

• Let them know you’ll be sending a case history and perhaps other forms to complete

• May be helpful to talk to the student on the phone to describe the procedures and obtain permission for a home video

Case History Form

• Important information:

• Changes in stuttering since onset

• Student’s own reaction and family’s reaction to stuttering

• Past treatment

• Impact of stuttering on school performance

• Video recording may be more stuttering at home or school than in clinic, so this is an important sample

Parent-Child Interview

• Observe the student’s speech with his parents while they are involved in an activity that promotes speech, such as how their favorite sports team is doing or describing a book or movie that they liked

• Video record this with the participants’ permission for later analyses and then pay close attention to both the student’s stuttering behaviors and the parents’ responses and interaction style.

Parent Interview

• Let parents know you support them and their child

• Fill in gaps from case history (see section on areas to discuss with parents of preschool child)

• Ask about how stuttering affects student in school (eg, participating, teasing, teacher responses, etc.)

• Try to determine if there are factors that would hinder recovery (eg, parent’s anxiety or negative attitude about stuttering, student’s sensitivity, motivation, etc.)

• Convey acceptance of family; comment on positive things they have done

Teacher Interview

• Make an alliance with the teacher

• Find out about child’s communication in class, if stuttering interferes with communication, how teacher responds to child’s stuttering, and if other children tease child about his stuttering

• What information might you want to give to the teacher about stuttering?

• Classroom observation

• Arrange a time with teacher to unobtrusively observe student when he may be talking in class

• Note how much he talks, to what extent he avoids, and how others react to his stuttering.

Student Interview

• Get to know student first—his likes, dislikes, family, etc.

• Discuss stuttering in a direct but accepting manner

• Make sure child experiences you as interested in him and accepting and curious about his stuttering

• Explore when he stutters the most, least

• What he does when he stutters (have him teach you)

• His feelings about his speaking

• Others’ reactions, teasing, parents’ responses

• Avoidances.

Speech Sample #1

• Preliminaries

  • Ask student’s permission to video record

  • Record 300 to 400 syllables of student’s conversation (10 minutes)

  • Obtain 200-syllable reading sample

• Offline: analysis of disfluencies; observe degree of tension, struggle, escape, avoidance; and estimate developmental/treatment level

• SSI-4

• Speech rate: compare with normal for age

Trial Therapy #1

• Have student catch clinician’s pretend stutters

• Have student put in pretend (or real) stutters, and have clinician catch student and reward him

• Have student control length of clinician’s pretend stutters (eg, by having student squeeze fist and keep clinician in stutter as long as student is squeezing fist)

• Roles reverse, and clinician signals student to make stutter longer and end it slowly and loosely (much reward when student is able to do this!)

• Can student hold onto stutter, reduce tension, and release stutter slowly with clinician’s coaching? On his own?

Feelings and Attitudes

• Methods of assessing:

  • Informally by observation and discussion with student

  • Informally with materials (eg, “worry ladder” from workbook by Chmela & Reardon, 2001)

  • Use formal assessment with discussion: CAT or A-19 and/or OASES for schoolage children

Other Speech and Language Disorders

• Observe articulation and language; test if needed

• Physical: Are there motor problems? Delay?

• Cognitive: Learning disability? Attention/activity problem? Intelligence?

• Social-emotional: Able to make friends? Highly sensitive or anxious?

• Academic adjustment: Academic performance problems? Reading problems?

Diagnosis and Closing Interview

• Developmental/treatment level

• Factors influencing persistence

• Closing interview in clinical setting

• Begin with positive aspects of child and family

• Be clear and direct when describing level of stuttering and implications for treatment

• Address family’s concerns about student’s future

• Discuss treatment options including family’s role

Public School Setting

• After evaluation, clinician writes brief report in lay terms

• Report should discuss affective, behavioral, and cognitive aspects of student’s stuttering and school performance

• IEP team meets to consider the severity of child’s stuttering and its impact on education including extracurricular activities

• Does student participate fully in school activities, or does stuttering limit him or her?

• Can student meet school’s curriculum objectives, especially those related to speaking?

• If IEP team determines child is eligible, measurable goals and short-term objectives are developed

• Services to meet these goals and objectives are determined.

Preassessment #1

• Clinic versus school assessment

• This evaluation described as though it is in a clinic

• When evaluation is in school, IEP process is followed

• IEP process gets input from students when they are 14 or older and eventually involves not only school-based treatment but transition plans as well

• Adolescents in school can fill out themselves with help from parents.

Preassessment #2

• Attitude questionnaires

• Sent to client several weeks before evaluation so they can be analyzed prior to interview

• Typically used: S-24, SSRSS, Locus of Control, OASES

• Also send “Personal Aims for the Stuttering Treatment” form AV recording

• Crucial to have recordings from out of clinic; best if difficult situation, like talking on the phone

• Analyze prior to evaluation.

Interview/Conversation

• Learn about adolescent’s strengths and interests

• Begin by letting client know what will take place in the evaluation

• Ask open-ended question like “Why don’t you begin by telling me about your stuttering?”

• After client has finished an initial description of concerns, ask about onset, development, and early experiences

• How would you elicit this information?

• Ask about current stuttering and how it affects social, occupational, and academic situations

• Explore feelings—use results of questionnaires (S-24, etc.) as a basis to explore further

• Explore client’s awareness of current stuttering including escape and avoidance behaviors

• Does client have questions?

Speech Sample #2

• Use video recording of client talking about a familiar topic such as school of work, 300 syllables or more

• Reading sample at appropriate level

• Also sample from outside clinic; if none available, record client making a phone call

• Analyze with SSI-4

• Speech rate

• Pattern of stuttering

Trial Therapy #2

• Have client freeze a moment of stuttering, maintaining posture and tension; client should get sound flowing even with posture stopped

• This may require some coaching, especially on stop sounds

• Have client become aware and describe what he’s doing as he stutters

• Show your accepting curiosity as you help child feel what he’s doing as he stutters

Trial Therapy #3

• Have client stay in posture and become comfortable in the posture with sound flowing, via your coaching

• When client is comfortable, tension will reduce

• Then client should finish the word loosely and slowly

• See if client can do this (staying in stutter and releasing slowly) on his or her own after some clinician-guided practice

Interview: Family of Adolescent

• Convey sincere acceptance of family’s viewpoint and concerns

• Give family opportunity to express their concerns and emotions and to get their view of the adolescent’s stuttering

• Give some time for adolescent to express views and feelings privately

• In closing interview with adolescent and family, give principle role in treatment to adolescent, but involve family as much as adolescent is comfortable with

Diagnosis

• Determine if this is “developmental” stuttering rather than normal disfluency, cluttering, neurogenic, or psychogenic stuttering

• How do you differentiate these?

• Intermediate stuttering

  • Younger than age 14

  • Blocks, repetitions, and prolongations

  • Escape and avoidance behaviors

  • Negative attitudes about speaking

• Advanced stuttering

  • 14 years or older

  • Symptoms as above but more entrenched

Closing Interview

• Focus on positive aspects first

• Describe stuttering behaviors, feelings, and attitudes, and provide explanation as far as possible

• Describe therapy options, and give recommendations

• Provide client with assignments to start

• Set up next appointment if appropriate.

Preassessment #3

• Case history form sent to adults several weeks prior to evaluation

• Attitude questionnaires

  • Sent to client several weeks before evaluation so they can be analyzed prior to interview

  • Typically used: S-24, SSRSS, Locus of Control, OASES

  • Also send “Personal Aims for the Stuttering Treatment” form which is available in Chapter 9

• AV recording

  • Crucial to have recordings from out of clinic; best if difficult situation, like talking on the phone

  • Analyze prior to evaluation.

Interview

• Begin by letting client know what will take place in the evaluation

• Ask open-ended question like “Why don’t you begin by telling me about your stuttering?”

• After client has finished an initial description of concerns, ask about onset, development, and early experiences

• How would you elicit this information?

• Ask about current stuttering and how it affects social, occupational, and academic situations

• Explore feelings—use results of questionnaires (S-24, etc.) as a basis to explore further

• Explore client’s awareness of current stuttering including escape and avoidance behaviors

• Does client have questions?

Speech Sample

• Use video recording of client talking about a familiar topic such as school of work, 300 syllables or more

• Reading sample at appropriate level

• Also sample from outside clinic; if none available, record client making a phone call

• Analyze with SSI-4

• Speech rate

• Pattern of stuttering

Trial Therapy #4

• Have client freeze a moment of stuttering, maintaining posture and tension; client should get sound flowing even with posture stopped

• This may require some coaching, especially on stop sounds

• Have client become aware and describe what he’s doing as he stutters

• Show your accepting curiosity as you help child feel what he’s doing as he stutters

Trial Therapy #5

• Have client stay in posture and become comfortable in the posture with sound flowing, via your coaching

• When client is comfortable, tension will reduce

• Then client should finish the word loosely and slowly

• See if client can do this (staying in stutter and releasing slowly) on his or her own after some clinician-guided practice

Other Speech and Language Behaviors

• Informally screen or formally assess language, articulation, voice

• Screen hearing

• Other factors

• Intelligence

• Psychological and vocational adjustment

Diagnosis

• Determine if this is “developmental” stuttering rather than normal disfluency, cluttering, neurogenic, or psychogenic stuttering

• Determine what treatment level is appropriate

• Advanced stuttering

• 14 years or older

• Symptoms as above but more entrenched

Closing Interview

• Focus on positive aspects first

• Describe stuttering behaviors, feelings, and attitudes, and provide explanation as far as possible

• Describe therapy options, and give recommendations

• Provide client with assignments to start

• Set up next appointment if appropriate.