Assessment: Younger Preschool

The substantial majority of PRESCHOOLERS referred for a fluency evaluation exhibit _________________ to ______________ stuttering.

moderate to severe

Key Diagnostic Considerations for Preschool Children vs. Adults/Teens:

• Role of the parents in case history and the evaluation itself

• Accuracy of the stuttering history information

• Lack of clarity regarding the emotional factors

• Possibility of CONCOMITANT DISORDERS

• Challenges of eliciting representative speech sample

Adults/teens typically give their own...

case history

In preschoolers, parents are the main providers of what?

history information AND are critical collectors of data about the disfluencies that have been observed

Being so close to the younger preschooler, parents are a critical part of the fluency assessment...

• The parents own background - is there a family history of stuttering?

• Parents experience with stuttering

• Parent personality

• The atmosphere they create at home

• Their attitude and reactions to the child's stuttering - important for us to understand the child's problems and factors that aggravate the child's stuttering

• Parents make the ultimate decision about the nature and timing of treatment for fluency

Parents of younger children, as opposed to the contrary, typically provide what type of information?

more accurate information with greater validity and in greater detail than what is obtained for older children (some data on disfluencies may be only days old)

For younger patients, they more often have more family that is still alive so ….

parents can gain more accurate historical information about stuttering and concomitant disorders

An assessment for fluency for a younger preschooler should include an assessment of....

language, speech, and hearing

what are present in a substantial amount of patients? (example?)

concomitant disorders

Issues with phonology and language are more prevalent as occuring with stuttering than in NFC.

Elicitation of speech samples is not always easy with the younger population. why?

1. Children may not speak

2. They may not feel comfortable

3. They may not be as disfluent as their parents have reported

Evaluation: Objectives

Let’s check these off as part of our assessment

• Case and family history

• Quantified disfluent speech

• Other domains & contributing factors

• Prognosis and recommendations

• Initial parent counseling

• Child’s reactions

• Other domains

Case history: Important information

• Exact time of onset – what was going on at this time?

• Manner of onset (gradual-sudden) why does this matter? Why do we care as clinicians?

• Circumstances of onset – why does this matter?

• Initial stuttering; changes over time (features and severity)

• Family’s stuttering history

Should the child be present during the parent interview?

Pros?

Cons?

Pros: examples, see how the child reacts

Cons: feeling embarrassed, distracting, parent may omit info

Parent interview considerations

• Let parents know the overall flow of the evaluation – you are looking at fluency and other areas as well

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

• Careful, nonjudgmental listening is important

• Leave time at end for parents’ questions

• Recall, that this unlike other disorders is essentially a LOSS of fluency as the parents have likely heard the child be fluent

For younger children, there are behavior/attitude scales similar to the OASES...

KiddyCAT (Communication Attitude Test for Preschool and Kindergarten Children Who Stutter) - starts ages 3 to 6 years old

BAB (Behavior Assessment Battery for School-Age Children Who Stutter) - starts at age 6

what should you ask parents what was observed near onset and now?

speech disfluencies, secondary characteristics, overall stuttering severity

child and clinician interaction is an opportunity to observe what?

child’s stuttering and his response to various stimuli

IF the child is quite fluent, the clinician may do what to see if stuttering appears?

speak rapidly and ask many questions

If the child is stuttering, the clinician may do what to see if there is a change in the stuttering behaviors?

experiment with fluency facilitating interactions such as speaking slowly

If the child is aware, what should you discuss with the parents?

the benefits of talking to child about stuttering

what are the benefits to talking about stuttering?

stuttering is not bad, increase self-advocacy, huge relief

The clinician can ask the child if he/she ever does what in a child and clinician interaction?

gets stuck on words or has trouble talking

Children are usually relieved by what type of discussions of stuttering?

open and reassuring

If the child is reluctant to talk or play with the clinician, what should you do?

it's important not to push; the clinician can play with an appealing toy and talk to themselves, and eventually the child may join

awareness check

1. parent report

2. direct questioning

3. the puppet test

parent report- awareness check

ask parent directly if they feel the child is aware and how or why they feel that way and how strong they feel the emotions are regarding the awareness if any

direct questioning- awareness check

ask the child if he/she is a good talker or ever feels like they make mistakes during talking – you can then voluntary stutter and ask if they know anyone else that talks like that? Note verbal reply and other reactions

the puppet test- awareness check

two puppets, one stutters and one does not on the same sentence, you then ask the child which one talks like them, you may have to repeat the procedure a few times –

“I I I I l lll ove Pizza….”

ALWAYS gain parent permission for what parts of the awareness check

direct questioning and puppet test

(is it ok if I ask your child about stuttering?)

How to elicit speech/language samples in preschoolers:

• Play sample/s

• Parent interaction sample/s

• Parents may bring in a recording you may use

How many do we want ideally and how many words??

2 contexts, 300 words

Disfluency count formula...

(number of stuttered words x 100)/number of words in a sample

Diagnosis: Determining Developmental/Treatment Levels

1. typical disfluency

2. borderline

3. beginning

typically borderline and beginning are combined

parent counseling

• Summary of findings

• Considerations for intervention – are you going to recommend tx or not right now?

• Information about stuttering

• Advice to parents

Advice to parents

• Home environment

• Handling stuttering events

Recommendations for Children with Typical Disfluency

• Give information about normal/typical 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: e.g., turn-taking, careful listening, appropriate speech rates

Recommendations for Children with 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

Recommendations for Child with Borderline Stuttering:

• Discuss with parents the option of indirect treatment or watchful waiting

• Provide video/resource information Stuttering and the Preschool Child

• Have parents share weekly results of SR scale – parents can be taught to track their child’s severity

Recommendations for Child with Beginning Stuttering:

• Discuss indirect versus direct treatment

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

Recommendations for both Beginning AND Borderline Stuttering:

Answer questions and provide contact information so parents can stay in touch if needed before next appointment

Advice to parents: Home environment

• Decrease various pressures -

• Decrease emotional and physical excitement

• More relaxed, slow paced activities

• Speak slower, especially to child

• Promote child’s self confidence.

Advice to parents: Handling Stuttering

• Listen patiently as child stutters

• Repeat child’s stuttered word: easily and stretched a bit

• More direct suggestion: “say this easily again”; “let’s say it easily together”

• Reinforce fluency: “this was easy”

• Show empathy: “Sometimes speech is difficult”

Food for thought/Opinions/Changes with the current climate in our country and globally – newer information

• Make sure your patient wants to be more fluent and focus on communication as a whole and NOT just on fluency.

• We really need to see what our parents and patients want and what they are looking for so we can work with each individual patient to meet their needs.