Module #4.2. Differential Assessment and Diagnosis of Preschool Fluency Disorders

Fluency Assessment Basics Across the Lifespan

Many of the same assessment components are utilized throughout a client’s lifespan, though specific focus may shift depending on age. The assessment of preschool children requires a comprehensive approach to determine the nature of their speech patterns.

• Core Assessment Components:
  • Written Case History: Reviewing cumulative files and previous records.
  • Intake Interview: Gathering direct input from parents and caregivers regarding the child's development.
  • Caregiver Perspective: Identifying the parents' or caregivers' view of the communicative problem.
  • Medical and Family History: Documenting history of stuttering in the family, results of hearing screenings, and other relevant medical risk factors.
  • Inter-professional Information: Collecting input from other sources, such as teacher reports.
  • Standardized and Non-Standardized Assessments: Utilizing formal testing alongside informal clinical observations.
  • Speech Sampling: Obtaining a representative sample of the child’s natural speech.
  • Speech Analysis: Analyzing the rate of speech and the severity of disfluencies.
  • Feelings and Attitudes: Conducting interviews to assess the client's internal reactions, impact, and feelings toward their stuttering.
  • Orofacial Examination: Evaluating the structural and functional integrity of the speech mechanism.

Key Questions for Clinical Consideration

During the assessment process, the clinician must answer several critical questions to guide the diagnosis and treatment plan:

• Is the child presenting with genuine stuttering behaviors or typical disfluencies?
• What is the severity and variability of the child's stuttering behaviors?
• Which specific assessments are required to gain the necessary clinical information?
• What is the most effective way to report the findings to the family and other stakeholders?
• What information will help determine present levels of performance to establish appropriate goals if therapy is indicated?

Differential Diagnosis: Normal Disfluencies vs. Stuttering

Distinguishing between typical developmental disfluency and actual stuttering is the primary goal of the preschool assessment.

• Typical Disfluency:

  • Speech Characteristics: Multisyllabic whole-word repetitions, phrase repetitions, interjections, and revisions.
  • Associated Behaviors: No physical tension or struggle; no secondary behaviors; no negative reactions or frustration; no family history of stuttering.

• Stuttering:

  • Speech Characteristics: Sound or syllable repetitions, prolongations, and blocks.
  • Associated Behaviors: Physical tension or struggle; secondary behaviors (e.g., eye blinks, facial grimacing, changes in pitch or loudness); negative reactions or frustration; avoidance behaviors (e.g., reduced verbal output, word/situational avoidances); presence of family history of stuttering.

Standardized Assessment Instruments

Several standardized tools are available to measure various aspects of stuttering and temperament in preschoolers:

• Test of Childhood Stuttering (TOCS):

  • Age Range: $4-12$ years.
  • Purpose: Measures stuttering severity, analyzes specific moments of stuttering, and documents change over time. It includes rating scales for parents and teachers.

• Stuttering Severity Instrument, Fourth Edition (SSI-4):

  • Age Range: $2;10$ years and up.
  • Purpose: Provides a severity score based on observable aspects: frequency, duration, physical concomitants, and the naturalness of speech.

• KiddyCAT: Communication Attitude Test for Preschool and Kindergarten Children Who Stutter:

  • Age Range: $3-6$ years.
  • Purpose: A $12$-item questionnaire that gauges a child’s attitudes about speaking and explores the behavioral and psychological impact of stuttering.

• Behavioral Style Questionnaire (BSQ):

  • Age Range: $3-7$ years.
  • Purpose: Aims to predict temperament types that may be associated with stuttering.

• Children’s Behavior Questionnaire:

  • Age Range: $3-7$ years.
  • Purpose: Assesses specific temperament domains in young children, including:
    • Activity level
    • Anger/frustration
    • Approach
    • Attentional focusing
    • Discomfort
    • Falling reactivity and soothability
    • Fear
    • High intensity pleasure
    • Impulsivity
    • Inhibitory control
    • Low intensity pleasure
    • Perceptual sensitivity
    • Sadness
    • Shyness
    • Smiling and laughter

Non-Standardized Assessment: Speech Sampling

A thorough speech sample analysis provides critical data that standardized tests may miss. Clinicians should observe:

• Metric Analysis: Total number of disfluencies per sample, frequencies of different disfluency types, and specific disfluency indexes.
• Temporal Characteristics: Duration of individual instances of disfluency and overall speech rate.
• Qualitative Observations: Types and frequencies of secondary behaviors.
• Home Sampling: Parents are encouraged to provide an audio or video recording of the child speaking spontaneously at home. This often captures stuttering that may be more severe than what is seen in the clinic. A $5-10$ minute video of parent-child play is recommended. To acclimate the child to being filmed, parents can leave the camera on a stand for several days before recording.

Parent Interview and Case History

The initial evaluation should begin with building rapport. Allowing parents to interact with the child while the clinician observes provides a naturalistic sample. The interview itself should be nonjudgmental and open-ended.

Common Interview Questions:

1. Describe complications with pregnancy or birth.
2. Describe speech and language development compared to siblings and expectations.
3. Describe other speech or language disorders in the family.
4. When was the disfluency first noticed?
5. Were there any special life events coinciding with the start of stuttering?
6. Describe the initial disfluencies.
7. What changes have been observed in speech since onset?
8. Is the child aware of the disfluency?
9. Does the child change words to avoid disfluency?
10. Does the child avoid talking in certain situations?
11. How do you (the parent) feel about the disfluencies?
12. What strategies or interventions have been tried?
13. What was the outcome of those strategies?
14. In what situations is the child more or less fluent?
15. How does the child get along with others?
16. Describe the child’s temperament.
17. What is a typical day like for the child?
18. Is there anything else to help understand the child’s stuttering?

Parent-Child Interaction Analysis

Observing parent-child interaction (ideally video-recorded) helps the clinician observe the child’s awareness and the parental interaction style without the clinician's presence introducing bias. Clinicians should look for:

• Frequency of parent interruptions.
• Whether parents talk at a high rate of speed.
• Usage of complex vocabulary or advanced syntax by the parents.

Determining Developmental and Treatment Levels

• Typical Disfluency: Observed when there are fewer than $10$ disfluencies per $100$ words. Disfluencies typically consist of multisyllabic word/phrase repetitions, revisions, and interjections. Repeated units are usually limited to $2$ or fewer iterations and maintain a slow, regular tempo. The child is generally unaware.
• Borderline Stuttering: Characterized by more than $10$ disfluencies per $100$ words, though they remain loose and relaxed. Symptoms include part-word and whole-word repetitions with more than two iterations frequent in many repetitions.
• Beginning Stuttering: Usually occurs in children aged $3.6-6$ years. It involves physical tension (especially facial), a sense of hurry, and clear awareness/frustration. Escape behaviors and some avoidance may appear. Repetitions are rapid and abrupt; pitch may rise during repetitions and prolongations, and the child may have difficulty starting airflow.

Risk Factors for Persistent Stuttering

Clinicians prioritize identifying factors associated with the persistence of stuttering rather than recovery:

• Family History: Relatives with persistent stuttering.
• Gender: Stuttering is more likely to persist in boys.
• Speech/Language Skills: Status of overall communication development.
• Temperament: A sensitive temperament can be a factor.
• Reactions: Negative reactions from the child or the family.
• Communication Style: Exposure to complex language or high-pressure communication environments.
• Family Expectations: High expectations for academic, athletic, social, or verbal performance.
• Environmental Factors: Stressful life events, busy family schedules, or overscheduled homes.

Recommendations and Clinical Follow-up

• For Typical Disfluency: Provide information about normal development. Suggest environmental changes like consistent turn-taking and appropriate speech rates. Schedule a re-evaluation in several weeks if concerns persist.
• For Borderline Stuttering: Discuss options for indirect treatment or "watchful waiting." Teach parents to use a Severity Rating (SR) scale and share results weekly.
• For Beginning Stuttering: Discuss the choice between indirect and direct treatment. Parent-led SR scales should be utilized and reviewed weekly.
• Closing Interview: Discuss findings, identify family desires and expectations, and provide a recommendation sheet for immediate changes at home.