diagnostic concerns in fluency disorders
TRANSCRIPT
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Diagnostic concerns in fluency
disorders
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Fluency Assessment
DataCollection
Analysis &Interpretation
Information &Counseling
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Assessment Overview
Fluency Assessment
Plan for
Data Collection
Determine Goalsof Evaluation
Determine InformationNeeded
Select AssessmentTools
Generate
Dx Questions
Consider Resources
for Information
Client
FamilyTeachers
Objective
Measures
Interviews
Questionnaires
Self-Evaluations
Speech Samples:
Speech &Nonspeech Behaviors
Formal
Tests
Attitudes
Perceptions
Avoidance BehaviorHistory
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The goals of a fluency
evaluation
For young children: Do they stutter?
Developmental stuttering vs. normal disfluency vs. language formulationdisfluency
If they stutter, how likely is recovery? examination of risk factors
What is the appropriate next step? Monitoring, parental consultation Indirect management Direct management
For older children and adults: How significant is the stuttering problem?
In terms of overt symptoms In terms of associated behaviors, including frustration, fear, avoidance, and
perceptions of handicap and disability What factors affect fluency and associated affective and emotional states? What are the goals of fluency therapy?
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Appraising overt symptoms: the
speech sample
From children: Conversation with you and with the parents Narrative (e.g., Frog stories) Recreation of situations/contexts in which fluency is
reported to wax and wane
From adults: Monologue (may be done during case history)
Conversational interaction Reading Optional: appraise consistency and adaptation using
repeated reading of materials
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Tallying disfluencies (overt behaviors)
from the speech sample What gets counted?
Normal disfluencies
Stutter-like disfluencies (SLDs)
Calculating proportions what are your numerators and denominators?
Appraising frequency Via percent stuttered words or syllables
Problems with purely time-based measures
Describing typology What are the proportional incidences of major disfluency subtypes?
Reliability of behavioral measurements Tom exercise
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Examining accessory features
A tip: listen to the tape without looking,then look without listening
Things to look for: Atypical speech production postures Ancillary body movements
Eye gaze Sample assessment instruments: SSI-
3, Cooper Scales
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Attitude assessment
Potential
measures:
See samplehandouts
How does stuttering affect
the individuals everyday
behavior?
What are perceptions ofdisability and handicap?
How do they feel about
speaking and stuttering?
What do they know or
believe about their
stuttering?
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Goals of the assessment
For parents, what are the goals? Can
they supply more than one? Using goals to explore options
What are the clients goals?
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Dx summary
preschool children
Questions that need tobe answered: Is it stuttering? What is the likelihood of
spontaneous recovery? What has been done up
to now, with what
results? What are the pros and
cons of varioustreatment models?
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Preschoolers (continued)
Information required: Frequency, duration and types of disfluency Presence of struggle or tension
Presence of awareness and reactions tomoments of disfluency Assessment scales (see handouts)
Status of other speech/language abilities Parent-child communicative style Parents reactions and attitudes toward behaviors Parents understanding of the nature of stuttering Perceived risk factors for chronicity or worsening
of symptoms
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Preschoolers (continued)
Case history specifics: Parents information about onset, course of
disfluency patterns over time
Medical, social and developmental history Child and listener responses to disfluency Level of awareness, frustration, avoidance, self-
consciousness Reactions of others in the childs environment,
including advisements
Parents beliefs about cause of the problem Parents views of the childs personality and
temperament Family history of stuttering and other
communicative disorders
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Behavioral measures for pre-
schoolers: What are SLDs?
Stutter-like disfluencies include: Sound, syllable and monosyllabic whole word
repetitions
Weighted scores for disfluency take into account thenumber of iterations
Blocks, prolongations, broken words
Other disfluencies might include:
Interjections, filled pauses Revisions Multisyllabic word or phrase repetitions Hesitations
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Step Two: Assess predictors
of remission and chronicity
The facts: ~80% of children who begin to stutter will
recover (apparently without clinicalintervention) The time frame for remission may be more
limited than previously supposed (Yairi, et al.,
1996; Ramig, 1993)
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Predictors of chronicity andremission*
Gender
Time
since
onset
Family hx ofpersistence &
recovery
Age at
onset
Speech&language
skills
SLD's over12 mos.
post-onset
*from Yairi, Ambrose, Paden & Throneburg (1996),
JCommDis, 29, 51-77.
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Weighing the oddsMore
concern
Less
concern
Family history of chronic stuttering
Male
Stable or increasing pattern of Stutter-Like
Disfluencies (SLD's) over 12 mos.Stuttering onset after 36 months
Relatively poorer speech/language performance
No family history or history of
recovered stuttering
Female
Decrease in SLD's over 12 months
Early onset of symptoms
Strong speech/language skills
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Patterns to monitor
0
2
4
6
8
10
12
14
January April July Oc tober January April July Oct ober January
Recovery Chronic Immediate concern
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Watch and see, not wait and see
As in SLI, the rapid course of
remission, but uncertain future of
individual children requires thepartnership of parents and clinician to
actively monitor progress and
establish guidelines for implementingintervention (Paul, 2000)
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Dx summary: school-aged
children
Questions that need to be answered: How complex has problem become? (awareness, shame, guilt, self-image
as a CWS?)
Is any part of problem language-based?
What are relative contributions of physiological factors, psychologicalfactors, attitudes and learning?
What is childs perception of problem? How does it compare to the
parents perceptions?
What intervention strategies would be most beneficial?
In what capacities will parents/school be involved? Educational component
Coordination of services
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School-aged children
(continued)
Information required: Medical, developmental, social and educational history
Full understanding of speech/language abilities
Frequency, duration, concomitant behaviors Impact on emotional development
Parental/family/school reactions and attitudes toward
stuttering
Child and parents understanding of the nature of
stuttering
Previous speech therapy: approaches and outcomes
Listener reactions and responses to listener reactions
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The CALMS Model of Stuttering
(Healey, et al., 2001)
Affective - feelings, emotions, attitudes
Linguistic- language
skills, lang.
formulation
demands &
discourse
Cognitive- thoughts
- perceptions
- awareness
- understanding
Social - effects oftype of listener & sp. situation
Motor- Sensori-motorcontrol of speech movements
A E l f H th CALMS
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An Example of How the CALMS
Factors
Interact During a Speaking Situation
Motor- I wonder if myfluency targets will work? My
tongue and voice feel tense.
Social - I really dont want to talk withthis person. I feel pressure to talk in this
situation.
Cognitive- I hope I dont stutter.- Im not a good talker.
- I want to avoid talking
- People will laugh at me.
Affective- I feel embarrassed, Im confused,Im afraid, I hate my stuttering.
Linguistic- What am I goingto say? How will
I say this and
be fluent?
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School-aged children
(continued)
Parent interview: similar to that of preschoolers;adjust to be age-appropriate
Teacher interview General questions about achievement and social
development How does stuttering affect these areas? Reactions of students and staff to stuttering?
Childs reaction? Level of participation, verbally and nonverbally in
classroom and other school activities Information about services received at school
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Tips for interviewing young
children
Some basics: Dont be alarmed if child says, I dont
know or shrugs shoulders. Children arenot used to evaluating feelings. They dont
necessarily evade. Some children just
accept things the way they are.
Share something about yourself, and the
type of work you do: One of my jobs is to help kids talk better
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Talking to young children
(continued)
Use analogies and examples to help the child feel
comfortable talking about problems.
For example, One of my friends who comes to play with me is Josh.
He sometimes gets stuck when the teacher asks him to read to the
class. Does that ever happen to you? Use a marble maze with some marbles too large to flow freely. Have
some get stuck. Then say, This marble is s-s-s-stuck. That picture
on the wall was made by Josh. It shows how he crunches up his
face when he gets stuck. What kinds of things do you do?
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Some questions to ask young
children
Whom do you like to talk to? (At home, at school) Who talks the most/least (At home, at school) Who interrupts? Who do you interrupt?
Who are good talkers? When do you want to talk well?
Are there times you want to talk extra well? Do other people feel this way as well?
When do you want to talk more than you do? Who listens/pays attention? What do you like listeners to do when you talk to
them?
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Qualifying children for services
in the schools
Please see diagnostic considerations
for qualifying CWS under IDEA and
writing IEPs (separate handout).
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Dx summary - Adults
Questions you need to answer: What type of fluency disorder is it?
Developmental stuttering Cluttering Neurogenic stuttering Psychogenic stuttering
If developmental stuttering, what are the relativecontributions of physiological, psychological, attitudinalfactors and learning?
Why does the client seek tx now? goals?
How does disfluency affect clients communication and life? What intervention strategies will be most appropriate?
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Adults (continued)
What information will be needed? Disfluency types
Severity of the disorder
Percentage of disfluencies Concomitant behaviors
Fears and avoidances
Clients attitude toward disorder
Core and secondary behaviors Emotional reactions/attitudes
Social, vocational and lifestyle information
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Adults (continued)
Interview specifics: Onset and early development; how was stuttering handled in
family? What does client believe caused it?
Impact educationally, socially and vocationally
Outlook: hope for change, past tx experiences, motivation to
change
Patterns of recovery and relapse, situational variability
Family history
Level of fear of speaking and stuttering Avoidance patterns
Self-perceptions
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Adults (continued)
Measuring impairment, disability and
handicap (Yaruss & Quesal)
Speakers reaction to stuttering Functional communication
Quality of life
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Measuring speaker reactions:
tools
Watson (1998) Inventory ofcommunication attitudes
Ornstein & Manning (1985) Self-Efficacy Scale (SEA-Scale) for Adultswho Stutter
Andrews & Cutler (1974) adaptationof Ericksons S-Scale
Yaruss & Quesal (2000)
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Diagnostic interpretation
For children Provide data on prognostic indicators, and work
with parents to determine next steps, which
should include a minimum of active monitoringand counseling to palliate symptoms.
Introduce information about therapy approaches
Provide information and information sources to
help family explore stuttering.
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For adults: Explain the therapy approaches that you
offer, and explore acceptability to client.Is this what the client had in mind?
Negotiate the terms of therapy
Help them become informed consumers;provide information sources.