Assessment of Fluency Disorders

Stephen Tasko

Speech Pathology and Audiology

Western Michigan University

What is a fluency disorder? Stuttering

Developmental stuttering Psychogenic stuttering Neurogenic stuttering

Cluttering

(Developmental) StutteringCommon Features Breakdown in the fluidity and rhythm of speech Breakdowns include

Sound repetition Audible and silent prolongations

Typically occurs at the beginning of utterances May fluctuate a great deal across situations Stuttering influenced by environmental, linguistic and other communicative

pressures May delay (postpone) or avoid saying certain words/sounds etc Can have associated symptoms including overt body movements such as

facial twitches, grimaces, head jerking, extraneous limb movement etc (secondary behaviors)

Can have associated symptoms of anxiety, shame, fear and guilt

(Developmental) StutteringNatural History of disorder Begins in early childhood (preschool) Early stuttering may be difficult to distinguish from

normal disfluency Features of stuttering tend to change over time Spontaneous resolution is not uncommon

Prevalence: roughly 1% of population Lifetime incidence: ~ 4-5 %

In developed form, expectancy, fear and avoidance play significant roles

(Developmental) StutteringWho tends to stutter? Those with a family history of the disorder Slower developing/disordered speech and

language Boys more likely to stutter than girls Children who are “vulnerable” to stress*

Neurogenic StutteringNeuropathology Distinct from aphasia,

dysarthria, apraxia Observed following lesions

to Left and right hemisphere All lobes except occipital

lobe Cortical and subcortical

(BG; thalamus) structures

Some Features Part-word or phoneme

repetitions No patterns related to word

type Not restricted to initial

words No syllable stress effect Lack of anxiety or

secondary symptoms Less responsive to fluency-

enhancing conditions

Psychogenic Stuttering Stuttering secondary to emotional trauma or

stressSome Features Sudden onset, typically related to some event Repetition of initial or stressed word Fluency enhancing effects not observed No periods of stutter free speech Initially no interest in problem

Cluttering Daly, 1992

“Cluttering is a disorder of speech and language processing resulting in rapid, dysrhythmic, sporadic, unorganized, and frequently unintelligible speech. Accelerated speech is not always present, but an impairment in formulating language almost always is.”

Ten Significant Features of Cluttering: Expert Opinion (Daly & Cantrell, 2006)

Characteristic Telescopes or condenses words Lack of effective self-monitoring skills Lack of pauses between words; run-on sentences Lack of awareness Imprecise articulation Irregular speech rate Interjections; revisions; filler words Compulsive talker; verbose; circumlocutions Language disorganized; confused wording Seems to verbalize before adequate thought formulation

Agreement (%)93908383828280807875

Stuttering vs. Cluttering Pure cluttering considered relatively rare

Is it rare or do pure clutterers not seek treatment? Cluttering-stuttering more common

Clinical reports of about 1/3 of youngsters who stutter show signs of cluttering

The Assessment Process Case History Evaluating Attitudes Toward Problem Evaluating Stuttering Behavior Diagnostic Probes Summarizing and Making Recommendations

General Considerations Build rapport Age Audiotape session (videotape if possible)

Case History

Problem Description General

What is the problem? Why is this a problem

Specific Conditions when worse/better How do you get out of a stutter? How do you prevent a stutter? How do others react to your stuttering? How do you react to your stuttering and others reactions

to it? Can you predict or anticipate your stuttering?

Problem Description continued History

When did it start? Who identified it? Why do you think it started? Summarize the history of the stuttering.

Problem Description continued Family history of stuttering Medical history Pregnancy Family constellation Developmental information

Speech and language Intellectual Physical Emotional

Problem Description continued Attitudes Toward the Problem

Has your reaction to stuttering changed? Perceptions of others reactions and how you would

prefer them to react Situational avoidance (speaking and nonspeaking) Do you feel like you have control over your speech

or does it control you?

The measurement of attitudes and attitude change are essential parts of successful treatment!!

Attitude Scales A-19 Scale for children who stutter

19 Y-N questions Revised Erickson scale

Original items drawn from MMPI 24 T-F items with normative data

Perceptions of Stuttering Inventory (PSI) 60 questions 3 themes, struggle, avoidance, expectancy

Children’s attitude test 35 T-F questions Older children can self administer, younger children can be asked

questions

Additional InformationSelf rating of problem Overall How representative is speech today?

Therapy history and attitudes toward therapy Therapy history Expectations of therapy

Evaluating stuttering behavior Counting and sorting disfluencies Physical descriptions of disfluency Stuttering instruments Noting associated behaviors

Counting and Sorting DisfluencyTypes of disfluency Sound, syllable, word or phrase repetition Sound, syllable, word or phrase revision Prolongation Tense Pause (Block) Interjection Revisions

Circumlocution Counting disfluencies % stuttered syllables/% stuttered words Units vs. moments of disfluency

Physical description of disfluency How does the speech pattern change prior to

breakdown? What is happening at the moment of

breakdown? How does the client release from the

breakdown?

Physical description of disfluencyPhysiologic variables to consider Voicing Muscle Tension Movement (stoppage, choppiness) Rate of Speech Airflow/Aerodynamics

With additional consideration given to Effort, caution, tentative vs. free

Do behaviors serve a purpose?For example, Postponement Avoidance Starter behaviors Escape behaviors

Early disfluency vs. stutteringCommon observations in young children Whole-word repetition Sentence initiation Normal tempo Lack of awareness or concern Evidence of language formulation stress Episodic

Summary by Yairi (1997)Relative to normally fluent children, children who stutter exhibit 2-3x total disfluencies 5-6x stuttering-like disfluencies (SLD)* ↑ proportion of SLD/total disfluency ↑ proportion of part-word repetitions with ≥ 2 units 6x disfluency ‘clusters’ Longer disfluency clusters Repetitions with shorter successive interval between units 2x associated head and neck movements

*SLD= part-word repetition, disrhythmic phonation, tense pause

Things to look for in youngstersDuring Speech Frequency of disfluency Type of disfluency Evidence of struggle Rhythm of stuttering More adult patterns Associated behaviors Awareness, fear and

frustration

Other risk factors Gender

male Family history

Positive family history Speech language status

Concomitant speech/language issues

Duration >14-18 mos.

Age of onset Onset after 3.5 yrs

Speech Samples Reading aloud Picture Description Monologue: Job Description “Problem” areas (e.g. telephone)

Variables known to influence fluency Automatic speech

Counting Choral speaking

Use difficult material Whispered speech

Use difficult material Altered speech rate

Say it fast/slow Applying stress to client

Associated Behaviors

Selected Test Instruments Stuttering Severity Instrument (SSI-3) Overall Assessment of the Speaker’s

Experience of Stuttering (OASES) Provile of Stuttering Behavior

Stuttering Severity Instrument: SSI-3(Riley, 1994) Provides a percentile rank and “severity”

rating based on a composite of scores based upon Frequency of disfluency Duration of disfluency Presence of physical concomitants

Measurements based on Spontaneous speech and reading when literate Picture description if not literate

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

New Instrument (Yaruss and Quesel, 2006) Multi-faceted assessment tool Based on WHO definitions of health &

disability Designed for adults Relatively quick to administer (~20 minutes) Undergone validation with normative data

Overall Assessment of the Speaker’s Experience of Stuttering (OASES) Four content areas

Section I: General Information Assesses self-perception of impairment, fluency, speech naturalness Assesses knowledge about self-help and treatment options.

Section II: Your Reactions to Stuttering Assesses the affective, behavioral, and cognitive reactions to stuttering

Section III: Communication in Daily Situations Assesses the client’s situational difficulties (work, social, home)

Section IV: Quality of Life Assesses the negative impact of stuttering on the client’s life.

100 questions Yield 4 focused scales, plus an overall scale

Profile of Stuttering Behavior (Van Riper)

Developed to measure Frequency Intensity Duration Postponement/avoidance

Provides a profile that is well suited for evaluating therapy progress

Diagnostic Probes

Summarizing and Making Recommendations