Module #4.3. Differential Assessment and Diagnosis: Adolescents & Adults who Stutter

Public School and Clinic Setting Considerations

  • Public School Evaluation and Treatment Procedures

    • Procedures are governed by the Individuals with Disabilities Education Act (IDEA) as well as specific state laws.
    • The SLP Process in Schools:
    • Following a referral for stuttering, the Speech-Language Pathologist (SLP) performs a discreet observation within the classroom setting.
    • The SLP confers with the teacher and the special education administrator regarding the student's fluency.
    • Parents are contacted to obtain formal permission for an evaluation.
    • An evaluation is conducted once consent is secured.
    • A collaborative team—consisting of the SLP, teacher, special education administrator, and parents—discusses potential treatment options.
    • Student Involvement: When a student is 1414 years old or older, their input is a mandatory requirement in the IEP (Individualized Education Program) process.

  • Clinic Setting Considerations

    • Initial contact often involves a telephone call to the family to manage expectations regarding the evaluation.
    • The SLP explains all pertinent forms that must be completed, such as the case history.
    • Families are requested to provide a video-recorded speech sample collected in the home environment.
    • Speaking with the client directly over the phone prior to the visit can be helpful for describing procedures.

Fundamentals of Fluency Assessment Across the Lifespan

  • Consistent Assessment Components
    • Written Case History: Review of cumulative files and relevant background forms.
    • Intake Interview: Heavily reliant on parent input for younger clients.
    • Medical and Family History: Includes a history of stuttering in the family, results of hearing screenings, and other identified risk factors.
    • Inter-professional Information: Input from teachers or other relevant professionals.
    • Educational Impact: For school-aged children, the SLP must determine if the stuttering affects their education.
    • Speech Observation: Observing the client's speech across a variety of speaking situations.
    • Formal and Informal Testing: Conducting both standardized and non-standardized assessments.
    • Speech Sampling: Obtaining samples from multiple settings (e.g., home, school).
    • Speech Analysis: Calculating speech rate and the severity of disfluencies.
    • Affective Assessment: Assessing the client's feelings, attitudes, and reactions to their own speech through interviews.
    • Orofacial Examination: A physical examination of the oral mechanism.

Information Requirements for Adolescents and Adults

  • Adolescent Assessment Needs

    • Understanding both the severity and the inherent variability of stuttering behaviors.
    • Understanding the subjective experience of stuttering.
    • Advocating for the specific educational necessity required in a school setting.
    • Determining how other therapeutic goals might impact fluency.
    • Building a support system.
    • Encouraging the client toward self-advocacy.
    • Establishing appropriate goals that align with the interests of both the child and the parent(s).

  • Adult Assessment Needs

    • Understanding severity and variability.
    • Understanding the individual experience of stuttering.
    • Identifying situational fears or specific speaking difficulties.
    • Gauging attitudes and feelings about stuttering.
    • Understanding how the adult is impacted by stuttering in daily life.
    • Encouraging self-advocacy.
    • Establishing goals that align with the client’s personal objectives.

Comprehensive Case History and Documentation

  • Case History Form utility

    • Tracks changes in stuttering since the initial onset.
    • Documents the client's reaction to stuttering, as well as the reactions of others.
    • Records past treatment history and the outcomes of those interventions.
    • Evaluates the impact of stuttering on professional or academic performance.

  • Specific Data Points from Adult Case History Forms

    • History of Stuttering:
    • Physical location of the first blocks (e.g., tongue, lips, chest, diaphragm, or throat).
    • Approximate duration of blocks on single words.
    • Presence of force or ease at onset.
    • Location of disfluencies (beginning of sentences vs. scattered throughout).
    • Early avoidance behaviors and initial reactions (surprise, anger, frustration, shame, indifference, etc.).
    • Developmental Changes:
    • Patterns of repetition, changes in force usage, voice loudness, and speech rate.
    • Periods of fluency vs. periods of increased stuttering.
    • Medical and Social History:
    • Handedness (Right, Left, or Both).
    • Evidence of visual or artistic abilities in the family.
    • History of significant illnesses, injuries, operations, and fevers.
    • Presence of chronic illnesses, allergies, or physical disabilities.
    • Handedness and sensory status (Vision and Hearing).
    • Mother's health during pregnancy and birth history/complications.
    • Current Stuttering Status:
    • Specific difficult situations (e.g., talking to superiors, naming yourself, using the telephone, strangers, reciting memorized material).
    • Impact on daily life, career, school, and social relationships.

Interview Procedures and Qualitative Analysis

  • Pre-assessment Questionnaires

    • Sent to the client several weeks prior to the evaluation for analysis.
    • Commonly used tools: S-24, Locus of Control, and OASES.

  • AV Recording Requirements

    • Recordings from outside the clinic are characterized as "crucial."
    • Recommended scenarios include difficult situations, such as talking on the phone.

  • Client Interview Structure

    • Open with an explanation of the evaluation process.
    • Use open-ended prompts: "Tell me about your stuttering…"
    • Discuss onset, development, and early experiences once the initial description is finished.
    • Explore how stuttering affects social, occupational, and academic domains.
    • Use questionnaire results (e.g., S-24) as a basis for further exploration of feelings.
    • Evaluate client awareness of stuttering, including escape and avoidance behaviors.

  • Sample Interview Questions (Zebrowski, Anderson, & Conture, 2022)

    • "Can you describe or show me what happens/what you do when you stutter?"
    • "How has your life been affected by stuttering? How would it be different if you didn’t stutter?"
    • "Why have you decided to look for help now?"
    • "What do you think other people think of your stuttering?"
    • "Do you ever talk about stuttering with anyone?"

  • Parent and Caregiver Interviews

    • SLPs should convey sincere acceptance of the family's concerns.
    • Provide time for the adolescent to express their views privately.
    • When closing, the SLP should give the adolescent the primary role in treatment and involve the family to the extent the adolescent is comfortable.

Specialized Assessment Tools and Scales

  • Stuttering Severity Instrument (SSI-4)

    • Normed for ages 2;102;10 and older.
    • Measures observable aspects: frequency, duration, physical concomitants, and naturalness of speech.

  • Overall Assessment of the Speaker’s Experience of Stuttering (OASES)

    • OASES-T (Teens): Ages 13−1713 - 17 (8080 items).
    • OASES-A (Adults): Ages 1818 or older (100100 items).
    • Measures 4 domains: General Information; Affective, Behavioral, and Cognitive reactions; Communication difficulties in key situations; and Impact on quality of life.

  • Unhelpful Thoughts and Beliefs About Stuttering (UTBAS)

    • A brief 6-item version exists, derived from a full 198198-question version.
    • Screens for speech-related social anxiety.

  • Behavioral Assessment Battery for School-age Children Who Stutter

    • Intended for ages 6−156 - 15.
    • Includes: Speech Situation Checklists (SSC-Er & SSC-SD), The Behavioral Checklist (BCL) of coping responses, and The Communication Attitude Test (CAT).

  • Self-Stigma of Stuttering Scale (4S)

    • Measures levels of self-stigma in older teens and adults.
    • Covers 3 domains: Self-esteem, Self-efficacy, and Life satisfaction.

  • Iowa Scales

    • Iowa Scale of Attitudes Toward Stuttering: A 4545-item scale where lower scores indicate better attitudes.
    • Perceptions of Stuttering Inventory (PSI): A 6060-item scale assessing avoidance, struggle, and expectancy.

  • Locus of Control Assessments

    • Addresses the "loss of control" phenomenon frequently reported by people who stutter.

  • Self-efficacy Scaling by Adult Stutterers

    • Measures confidence in entering speaking situations outside of treatment.
    • Scores are averaged across 5050 different speaking situations.

  • Behavior Assessment Battery for Adults Who Stutter (BAB-AWS)

    • An online-only, self-report assessment containing 44 tools focused on affective, behavioral, and cognitive dimensions.

  • Stages of Change

    • Based on the transtheoretical model of stuttering.
    • Assesses readiness to change, situational confidence, and negative thoughts.

  • Palin Parent Rating Scales (Palin PRS)

    • A 1919-item questionnaire for parents of children aged 3−153 - 15.
    • Measures stuttering impact, parent knowledge, and parental confidence.

Speech Sample Analysis, Diagnosis, and Closing

  • Speech Sample Metrics

    • Quantitative Data: Total number of disfluencies, frequency of specific disfluency types, disfluency indexes.
    • Duration: Length of individual disfluency instances.
    • Speech Rate: Calculated speed of delivery.
    • Secondary Behaviors: Frequency and types.

  • Diagnosis and Treatment Levels

    • Intermediate Stuttering:
    • Younger than age 1414.
    • Characterized by blocks, repetitions, prolongations.
    • Presence of escape and avoidance behaviors.
    • Negative attitudes about speaking.
    • Advanced Stuttering:
    • Age 1414 or older.
    • Similar symptoms to Intermediate, but with more entrenched negative attitudes toward themselves as a speaker and their speech, often due to the duration of time they have been stuttering.

  • Closing the Evaluation Interview

    • Begin by focusing on positive aspects first.
    • Summarize impressions of core and secondary behaviors, as well as attitudes and feelings.
    • Describe therapy options and provide recommendations.
    • Answer the client’s questions.
    • Schedule future appointments or an IEP meeting if in a school setting.

Questions & Discussion

  • Reflective Activity: A Slido poll was utilized to allow participants to answer reflective questions during the session (accessible via the link: https://app.sli.do/event/hYDwStVxJfAmpjUvLynSWs/embed/polls/f89612d2-4b44-482a-9195-6f2f1319d713).