Assessment

AssessmentWhats need in a speech and lang eval?Family Hx, Hx of whats going on/when it started, Birth Hx, Medical Hx, info about speech and lang (did they talk on time, what was the first word, were they intelligible?) 1Stuttering is one of the most extensively studied yet poorly understood communicative disorders.

Authorities in fluency disorders do not agree on a universal definition or on an etiology.

The disagreements about causation do not significantly influence the assessment process because it is possible to validly detect and assess stuttering without knowing the etiology.Serial Assessmentsmultple assessments, we know their fluency will vary depending on what situation theyre in.

2Overview of Assessment

HISTORY OF CLIENT:ProceduresWritten case historyInformation-getting interviewInformation from other professionalsContributing FactorsMedical or neurological factorsFamily historySex, motivation, and levels of concernBE NICE AND CARING TO YOUR PATIENT/THEIR FAMILY---they will be scared going into thisGetting info from other professionalsteachers, doctors, caregivers

3Cont. Overview of AssessmentASSESSMENT OF FLUENCYProceduresScreeningSpeech samplingStimulabilityAnalysisDyfluency indexesAssociated motor behaviorsOther physiological factorsRate of speechFeelings, Attitudes, and Reactions to SpeechSpeech/Language sampleconversational speechIf they are old enough, get a reading sample (of the child reading) so you can compareA little therapy within Dx session, to see how child respondsDisfluency indexescount out in speech sample how many disfluency he displays (how long, how many, types)? Get a percentage so you can compare to normative ageAssociated motor behaviorsaka secondary behaviorsRate of speechimportant for knowing the difference between cluttering (rapid rate of speech) and stutteringDo they have negative feelings? It would put them in a higher category4Cont.Overview of AssessmentORAL-FACIAL EXAMINATIONHEARING ASSESSMENTDETERMING THE DIAGNOSISPROVIDING INFORMATIONWritten reportInterviewCommunity resourcesSupport GroupsOral Mech examoral cavity integrity and functionability are within normal limits. Hearing should be within normal limitsCommunity resourcesthey may need help in other areas than SLP, they may need family counseling, stuttering support groups, parents/adults of child may need help as well

5History of the ClientImportant for risk factorsfinding triggers (ex: adult who goes in and out of fluency at different points in his life)differential diagnosis Ex: Child with Tourette's and chronic stutterer; tick disorderresearch now shows that ADD medication may worsen or trigger ticks. 6Assessment of FluencyScreeningThe most important procedure for a stuttering evaluation is a speech sampleObtaining speech samples for more than one session and setting is recommended. Clinic/testing siteOutside the assessment areaHomeClassroomPlaygroundWork Obtain the most representative sample possible Fewest dysfluenciesMost dysfluenciesTypical # of dysfluencies

Get a broad speech sample for a variety of settingsthis is the most accurate way

7screeningImportant because it will be the primary basis on which most analyses and judgments about fluency are made8Collecting a speech sampleEstablish a positive rapport prior to collecting sampleStrive for a long sample ( 200+ utterances)Alter the contextsConversation/ conversational startersNarratives (for reading aloud)Response/description of pictures (have the child describe whats going on in picture)

9Collecting a speech sampleAvoid yes/no questionsBe willing to WAIT for the client to talkUse a good quality recorder/videoPreselect materials and topics that will be interesting to the client

10Evaluating the Speech SampleDetermineTotal # of dysfluenciesFrequencies of different types of dysfluenciesDysfluency indexesDuration of individual instances of dysfluencyTypes and frequencies of associated motor behaviors11Descriptions of Dysfluencies(Hedge, 1999)RepetitionsPart word repetitions What t-t-t time is it?Whole word repetitions What what what are you doing?Phrase repetitions I want to- I want to- I want to do it.12Description of DysfluenciesProlongationsSound/syllable prolongations Llllllet me do itSilent prolongations A struggling attempt to say a word when there is no sound

13Descriptions of Dysfluencies InterjectionsSound/syllable interjections um.umI had a problem this morningWhole word interjections I had a well problem this morning.Phrase interjections I had a you know problem this morning.14Description of DysfluenciesSilent Pauses A silent duration within speech considered abnormal I was going to the (pause) store.Awkward sounding to a normal conversation; usually placed randomly in sentences

15Description of DysfluenciesBroken WordsA silent pause within words It was won(pause)derful.16Descriptions of DysfluenciesIncomplete PhrasesGrammatically incomplete utterances I dont know how to.Let us go, guysComplete stoppage of phrase and then moving on to something else (like circumlocution). 17Description of DysfluenciesRevisionsChanged words, ideas I thought I will write a letter, card18Dysfluency IndexesDysfluency Indexes refer to percentages of dysfluent speech present in the speech sample.

Index grids are helpful in identifying and quantifying dysfluencies19Dysfluency IndexesExamples of IndexesForm 9-1: The fluency Charting GridForm 9-2: Frequency Count for dysfluencies Form 9-3: Calculating the Dysfluency Index20Dysfluency IndexesExample:When determining a dysfluency index, count each repetition of a sound, part of a word, whole word, or phrase only ONCE. ba ba ba ba ballI want I want I want a ball

21Dysfluency IndexThe total dysfluency index reflects ALL dysfluencies produced by the client. 500 word sample: 75 repetitions 50 pauses 25 sound prolongations 150 total dysfluencies22Calculating the TDICount total number of words in speech sample (500)Count total dysfluencies (150)Total dysfluencies/total words (150/500=.30)30% TDI23Separate IndexesSpecific dysfluencies Total # of specific dysfluencies/total # of wordsTotal repetitions75/500=.15 (15%)

Percentage of each dysfluency typeTotal # of specific dysfluencies/total # of dysfluencies75/150=.50 (50% of dysfluencies present were repetitions)Important for knowing which type to target in therapythere are different techniques for all types/patterns24Duration IndexesTime each dysfluency with a stopwatch. Pauses and prolongations are the most commonly timed10 dysfluencies resulting in a total of 42 seconds yields an average duration of 4.2 seconds25Associated Motor BehaviorsExtraneous motor body movements in association with dysfluencies

Usually involve parts of the oral facial mechanism: eye blinking, wrinkling of the forehead, sudden exhaustive exhaling, frowning, distorting the mouth, moving the head and quivering the nostrils.Can involve arms, hands, legs, feet or torsoForm 9-4 Identify and chart the frequency of motor behaviors26Physiological FactorsRespiratoryPhonatoryArticulatoryProsodic aspects

Note if these features are present during fluent or dysfluent speech27Speech RateAssessing speech rate is an especially important element of the evaluationDetermine what you want to evaluate:Overall rate:Normal rate:

Are they very rapid? Are there intelligibility issues?Decide as you go what/how you want to evaluate it28Assessing Feelings and AttitudesS-Scale: assesses stutterers attitudes about various speaking situations. Form 9-6

Understanding a clients feelings and attitudes about his or her stuttering behavior may be helpful for making decisions about the clients care.

For young children, scales may be geared more towards parent and what they seeYou wont ask a child Do you think stuttering is hard? Do you think you are being teased? (youre putting ideas into their head for them)

29Assessing Feelings and AttitudesParental Concern:Particularly for children who stutterImportant to assess parental fears, anxieties and concerns that they have surrounding their childs stutteringEx: If you have a child who is mild stutterer (fluctuating between normal and borderline with no signs of anxiety or awareness) and mom and dad are highly concerned/upset. The parents reactions to the childs disfluency may exasperate the disfluency. They will probably ALL need therapyVs.Telling the parent the child is a mild stutterer and the parent is relieved, thats great newstell them to come back in 3-6 months for another evalVs. A child with severe stutterer and a parent who isnt concernedyou will have to work together

30Avoidance and ExpectancyTwo specific responses to negative feelings about stuttering are AVOIDANCE and EXPECTANCY

31AvoidanceSoundsWordsTopicsPeople (employer, teacher, strangers)Situations (ordering in a restaurant)Communicative Events (public speaking)32AvoidancePrimary AvoidancesStartersPostponementsRetrialsCircumlocutionsAntiexpectanciesSecondary AvoidancesReducing verbal output or not talking at allRelying on others to communicate for them

33Expectancy/AnticipationThe expectation of the stutter before it occursSome stutterers will push through the stutter when it occurs and others will avoid that situationAssess this by observing and listening during speech tasks and through interviews. You can suspect expectancy, but can only confirm this by asking the client34Criteria for Diagnosing StutteringClinicians must use their professional judgment and experience to make an appropriate diagnosis.The total dysfluency index: must be 5% or greater is usually considered a fluency disorderThe dysfluency indexes for repetitions, prolongations and pauses between words is 3% or greater is usually considered a fluency disorder The duration of dysfluencies are 1 second or longer usually warrant a diagnosis of a fluency disorder The presence of associated motor behaviorsThe client or caregivers degree of concern about dysfluency35Diagnosis in Young ChildrenDifferentiate between children with normal dysfluency and stuttering disorders?36Young ChildrenResearch shows that a child is more likely to outgrow stuttering if:The child is a girlThe onset is fairly recent (spontaneous recovery usually happens within 12-14 months of initial onset)The onset of stuttering occurred after the childs 3rd birthdayThe prevalence of sound/syllable or word repetitions declines quickly after onsetThe child demonstrates few to no associated motor behaviors and no articulation or language problems37Young ChildrenDiagnosis of stuttering if any one of these behaviors are present:Total % of dysfluencies is greater than 10% of all words or syllables uttered.Prolongations longer than 1 second on 2% or more of the words uttered. Increases in loudness, pitch rises, and abrupt termination of prolongations are additional indicators of a fluency disorderPart-word repetitions of two or more units per repetition on more of the words uttered.Involuntary blockings or hesitations that last longer than 2 secondsSigns of struggleNoticeable emotional reactionsComplaints of being unable to perform satisfactorily bc of speechObvious variations in the frequency or severity of speech disruptions with changes in speaking situations

38Estimating Severity Mild, Moderate, SevereStuttering Severity Instrument for Children and Adults : SSI (Riley 1994)Based on four major measures: frequency, duration, concomitant behaviors and overall severityUsed for all ages and yields a quick estimate for severitySSI: make sure to get a good audio/video sample so you can go back and tally. It isnt normal/natural to have a conversation with a person who is timing/tallying things---it will increase anxiety and disfluency (which wouldnt be an accurate sample). Do your ratings laterThere is a reading and nonreading section (for young children who cant read yet)Frequency, duration, and physical cocomitants (secondary behaviors?)Add up each total, divide to get percentages and compare to severity equivalenceGives different scores for different age ranges

Best practice is to take speech samples in MORE than one setting (clinical and out and about).

TYPES of disfluencies are important for which type of therapy you are going to target39Scale for Rating Severity of StutterRate speaker on 10 pt. scale (1 is no stutter;10 is most severe)Would it be possible for a clinician to rate an entire days worth of disfluencies? NoIts important to get parents and friends to use the rating scale for x amount of time as well.Very subjective measuremeasures disfluencies over timeGives clear parameters of what to look for in each level (1-10) unlike SSIFor this form, Very Severe is stuttering on 25% or more of words. As a clinician you would have to calculate this via language sample, a parent would just estimate. Includes child related, playmate, and parent related questions to ask for evaluation40Scale of Childrens Attitudes A-19Questions for child to answer (Yes or No format)Taps into emotional based questions without directly using word stutterBe careful not to put ideas into the patients headStutterers Self-Rating of Reactions to Speech SituationsFor adultsAnswer questions based on avoidance, reactions, and stuttering itselfHelps determine which core behaviors are more dominant