Module 4 #1 Differential Assessment and Diagnosis of School-Age Fluency Disorders
Overview of Differential Assessment and Diagnosis for School-age Children
The assessment and diagnosis of fluency disorders in school-age children is a multi-faceted process involving clinical observations, standardized testing, and collaboration between the Speech-Language Pathologist (SLP), parents, teachers, and school administrators.
The MSLP 546 course through Albizu University's Department of Speech-Language Pathology emphasizes that assessment must account for environmental settings (school vs. clinic) and the educational, social, and emotional impact of stuttering.
Public School Assessment Considerations
Legal Framework: The Individuals with Disabilities Education Act (IDEA) and specific state laws dictate the procedures for evaluating and treating students who stutter.
Initial Referral and Observation:
When a child is referred for stuttering, the SLP performs a discreet observation within the classroom environment.
The SLP confers with the teacher and the special education administrator to gather initial data.
Procedural Steps:
Parents must be contacted to discuss concerns and obtain informed consent for an evaluation.
The evaluation is conducted only after permission is secured.
A multidisciplinary team (SLP, teacher, special education administrator, and parents) meets to discuss treatment options based on evaluation findings.
Communicating with Parents:
SLPs should explain the school's desire to help the student become a more effective communicator.
It is essential to maintain a caring and accepting attitude.
Inquire if the family has observed the stuttering and explain the upcoming evaluation process.
Request that parents complete a comprehensive case history form.
Clinic Setting Considerations
Initial Communication: A telephone call is typically made to the family before the evaluation to set expectations.
Pre-Evaluation Tasks:
Clinicians explain necessary forms, such as the case history, that must be completed prior to the appointment.
Families are requested to provide a video-recorded speech sample of the child collected in the home environment to capture naturalistic disfluencies.
Client Engagement: If appropriate, the clinician may speak with the client directly over the phone to describe evaluation procedures and reduce anxiety.
Core Components of Fluency Assessment Across the Lifespan
Written Case History: Reviewing cumulative files and previous records.
Intake Interview: Gathering direct input from parents.
Medical and Family History:
Documenting a family history of stuttering.
Reviewing results of hearing screenings.
Identifying other potential risk factors.
Professional Input: Gathering information from teachers or other involved professionals.
Educational Impact: For school-age children, a primary focus is determining if the stuttering affects the child's educational performance.
Observational Speech Data: Observing speech in various speaking situations.
Assessment Methods: Utilizing both standardized and non-standardized tools.
Speech Sampling: Obtaining samples from multiple settings, including home and school.
Speech Analysis: Analyzing the rate of speech and the severity of disfluencies.
Feelings and Attitudes: Interviewing the client to assess their emotional reactions and attitudes toward their speech.
Physical Examination: Performing an orofacial examination to rule out structural or motor issues.
Specific Information Gathered via Case History
History of Stuttering Onset:
Approximate age when stuttering was first noticed.
Who first noticed the stuttering and in what situation.
Situations or conditions associated with the onset.
Circumstances occurring after initial onset.
Description of First Signs (Checklist):
Repetitions of the whole word (e.g., "boy-boy-boy").
Repetitions of the first letter (e.g., "b-b-b-boy").
Repetitions of the first syllable (e.g., "ca-ca-cat").
Complete blocks on the first letter (e.g., "b….oy").
Prolongations of the vowel (e.g., "caaaaaaaat").
Visible attempts to speak (mouth movement) with no sound forthcoming.
Stuttering Characteristics:
Duration of blocks (estimated length per word).
Presence of force or tension during onset.
Placement of stuttered words (beginning of sentences vs. scattered).
Presence of avoidance behaviors (changing words, stopping mid-stutter, or using gestures).
Use of "starters" (e.g., "hey mom, hey mom…") or fillers (e.g., "uh", "um").
Child's Reaction to Stuttering:
Awareness, indifference, fear, surprise, anger, frustration, or shame.
Developmental and Health Factors:
Presence of articulation or pronunciation problems.
Hand and foot preference (laterality).
Sensitivity or difficulty adapting to new situations.
Diagnoses of ADHD or ADD.
Fluctuation in stuttering (periods of disappearance or increase).
Situations that cause the most difficulty (e.g., asking questions, talking to strangers, using the telephone, reciting memorized material, speaking when excited).
Change in Symptoms Since Onset:
Increase in repetitions, force, or length of blocks.
Physical struggle (e.g., facial tension, eye blinks).
Secondary behaviors such as looking away from the listener or increase in pitch during stutters.
Medical/Family/Social History:
Prenatal and birth history (complications).
Developmental milestones (walking, talking, feeding).
Family history of speech, language, reading problems, or learning disabilities.
The Interview Process
Parent Interview:
Provide support and convey acceptance.
Fill in gaps from the case history.
Assess how stuttering affects school participation, teasing, and teacher responses.
Identify parental attitudes and their specific goals for therapy.
Teacher Interview:
Form an alliance with the teacher.
Inquire about classroom communication and if stuttering interferes with performance.
Ask about the teacher's response to stuttering and if the child is being bullied.
Student Interview:
Establish rapport first by discussing likes, dislikes, and family.
Discuss stuttering directly but in an accepting manner.
Ask the student to "teach" the SLP what they do during a stuttering event.
Explore feelings, attitudes, avoided words, and personal goals for therapy.
Classroom Observation
The SLP should arrange a time to unobtrusively observe the student when they are likely to be talking.
Observation Points:
Frequency of talking.
Extent of avoidant behavior.
Peer reactions to the student's stuttering.
The student's internal reaction to speaking out loud.
Standardized Assessment Tools
Test of Childhood Stuttering (TOCS):
Target Population: Ages to .
Purpose: Measures stuttering severity, analyzes disfluency moments, documents change over time, and includes rating scales for parents and teachers.
Stuttering Severity Instrument (SSI-4):
Target Population: Ages and up.
Purpose: Provides a severity score based on frequency, duration, physical concomitants, and naturalness of speech.
Behavioral Assessment Battery for School-age Children Who Stutter:
Target Population: Ages to .
Components:
Speech Situation Checklists (SSC-Er & SSC-SD): Evaluates emotional reactions and speech disruption across situations.
The Behavioral Checklist (BCL): Identifies coping responses.
The Communication Attitude Test (CAT): Measures attitudes about speech and educational impact.
OASES-S (Overall Assessment of the Speaker's Experience of Stuttering):
Target Population: School-age (ages to ).
Purpose: Assesses impact on educational performance, quality of life, and the child's perceptions of stuttering.
Integrative Child Temperament Screener (ICTS):
A -item scale gauging frustration, inhibition, and attention.
Child Behavior Checklist (CBCL):
Target Population: Ages to .
Purpose: Parent-completed checklist for emotional and behavioral problems.
Non-Standardized Assessment and Analysis
Parent/Teacher Questionnaires: Used for all school-age children to assess performance levels, social impact, and educational impact.
Teacher Assessment of Student Communicative Competence (TASCC): Specifically used to evaluate communication abilities in the classroom environment.
Speech Sample Analysis Metrics:
Total number of disfluencies.
Frequencies of specific disfluency types.
Disfluency indexes.
Duration of individual stuttering instances.
Overall speech rate.
Types and frequencies of secondary behaviors.
Diagnostic Criteria
A student typically meets diagnostic criteria if they exhibit:
Repetitions of sounds, syllables, or words.
Prolonged or blocked sounds.
A combined frequency of disfluencies greater than of all speech production.
Awareness of their own disfluencies.
Eligibility and Reporting in Schools
The Brief Report: Written in lay terms and should address affective (feelings), behavioral (actions), and cognitive (thoughts) aspects of stuttering.
IEP Team Meeting:
The team considers the severity of stuttering and its impact on education and extracurricular activities.
Questions to consider: Does the student participate fully? Does stuttering limit them? Can they meet curriculum objectives involving speaking?
Goal Development: If determined eligible, the team develops measurable goals and short-term objectives.
Recommendations: Recommendations must align with the setting (clinic vs. school) and the specific goals of the student and family. Further referrals (e.g., to a counselor or psychologist) should be identified if necessary.