Assessment of Fluency Disorders. / KUNNAMPALLIL GEJO JOHN

Assessment of fluency disorders
KUNNAMPALLIL GEJO JOHN, MASLP
10/23/2013
KUNNAMPALLIL GEJO JOHN
INDEX:
Introduction Reasons for evaluating fluency
Goals of assessment
Assessing Fluency disorders in Children Assessing Fluency disorders in adults
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INTRODUCTION:
Fluency
speakers effortless flow of speech.
Variables that determines the fluency - the temporal aspects of speech production.
Pauses, rhythms, intonation, stress and rate are controlled by when and how fast we move our speech structures. - Starkweather (1980,1987)
In his description of fluency, Starkweather also includes the effort with which a speaker speaks.
By effort, he means both mental and physical work a speaker must do to speak.
FLUENT SPEECH is continuous and the continuity of speech can be disrupted by hesitations of sound, syllables, words and phrases, prolongation of speech etc.
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Rate of speech, defined as the number of syllables uttered per unit of time, is another aspect of fluency.
However rate should be interpreted as a complementary factor in determining the fluency and therefore stuttering.
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Stuttering is most frequently seen fluency disorder The term stuttering means: 1. a) Disruption in the fluency of verbal expression, which is (b)characterized by involuntary, audible or silent repetitions or prolongations in the utterance of short speech elements namely; sounds, syllables, and words of one syllable. These disruption (c) usually occur frequently or are marked in character and (d) are not readily controllable. 2. Some times the disruptions are (e) accompanied by accessory activities involving the speech apparatus, related or unrelated body structures or stereotyped speech utterances. 3. Also there are not infrequently are (f) indications or report of the presence of an emotional state ranging from a general condition of excitement or tension to more specific emotions of a negative nature such as fear, embarrassment, irritation or the like.
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- Wingate (1964)
CLUTTERING is another fluency disorder in which speech fluency involves both the rate and rhythm of speech and resulting in impaired speech intelligibility.
Speech is erratic and dysrhythmic consisting of rapid and jerky spurts that produces gasps of words unrelated to grammatical structures of the sentence.
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REASONS FOR THE EVALUATING SPEECH FLUENCY
To determine whether the client has a fluency disorder or is at risk of developing one. To determine the type of fluency disorder
To identify the set of behaviors that defines the clients fluency (stuttering) problems.
To assess progress To assess the severity of the problem for finding eligibility, litigation and other purposes.
GOALS OF THE ASSESSMENT
To determine whether the problem exists that would require treatment, sometimes the severity of the problem and the prognosis regarding treatment cannot be determine from an initial assessment - Conture, 1997; Guitar, 1998.
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Initial Contact Case history form
Parent Interview
Preliminary assessment
Articulation Voice Oral Peripheral Language
Hearing Speech samples Fluency
Secondary behaviors Multiple part word repetitions, Prolongations, Pitch or loudness rise, Loss of eye contact, eye closures or 10 10/23/2013 KUNNAMPALLIL GEJO JOHN Hard onsets, Silent blocks, Distortions, blinking, audible inhalations, head or Struggle and tension body movements.
Primary behaviors
Differential diagnosis is an important element of fluency assessment - Ambrose & Yairi, 1999; Onslow & Packman, 2001.
Developmenta l Stuttering? Cluttering?
Which one is it?
Neurogenic Stuttering?
Stuttering like Dysfluencies?
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SOME CONSIDERATION Before getting into the assessment, a few things to be keep in mind when seeing a new client Every client is different Consider the person as well as the problem Diagnosis is an ongoing process
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ASSESSING FLUENCY DISORDERS IN CHILDREN First step in designing an appropriate program of management - Evaluation of the characteristics of a fluency disorder and the effect that disorder has on a patients ability to communicate The evaluation process involves the gathering of pertinent information (case history) from collecting data on the patients performance of various tasks from the patient and also from the care takers, as well as.
The speech pathologist to diagnose the fluency disorder, determine the relative efficacy of various treatment approaches and formulate a prognosis. 13 10/23/2013 KUNNAMPALLIL GEJO JOHN
What to evaluate?
The evaluation should address two basic aspects:
(a) (b)
The stuttering (moments and variability) and The concerned (the child, the parents, etc).
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1.
Evaluation and description of the dysfluency of the child:
Description should be in terms of the type of disruptions/blocks, frequency, duration, severity and the associated non speech behaviors. Types of disruptions/blocks: Look for core behaviors (Van Riper, 1982): repetitions, prolongations and blocks. Other types of blocks like interjections, revisions, and pauses may also be observed.
Frequency and duration of blocks: Children who stutter differ from each other on the frequency and duration. Usually stuttering frequency is greater than 5% and the average duration of a block may be around a second. Higher the frequency and longer the duration, the more severe the stuttering, Secondary behaviors: The associated non-speech behaviors may look like overt reactions that a child has acquired/learnt to release/prevent the core behavior.
2. Evaluation and description of the speech and language production in general: Language performance Mean length of utterance Rate of speech during instances of stuttering and fluent productions
Voice aspects during stuttering instances

Articulatory proficiency Oral peripheral mechanism Prosody
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Intelligibility of speech KUNNAMPALLIL GEJO JOHN
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Stuttering seems to have close links with speech language processing and production - Bloodstein, 2002
Children who stutter follow the same linguistic pattern as that of adults who stutter more on pronouns and conjunctions than nouns, verbs, adjectives and adverbs. In children the loci is identified as the beginning of syntactic units (sentences, clauses and phrases) and not as words initial positions.
A difficulty in linguistic planning and preparation - Bernstein Ratner, 1997 18 10/23/2013 KUNNAMPALLIL GEJO JOHN
Conture (2001) - Phoneme selection component of linguistic planning in children who stutter.
Associations with phonological skill, / speech production rate and speech motor systems skill / potential to execute fluent speech. Nearly 24 45 % of children who stutter exhibit some degree of articulation / phonological difficulties - Louko, Conture& Edwards, 1999
So evaluation should include aspects of language, phonology and other speech dimensions.
3.
Describe the developmental history ( speech and language )
Speech and language development history is important for us to make decisions of the capacity of the system to cope up with the processing load during speech and language acquisition.
The contention that stuttering occurs while the childs language acquisition proceeds rapidly than his developing motor system or is delayed causing frustration and difficulty in speaking, can be ascertained by nothing developmental history .
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4.
Track the pedigree
Stuttering tends to run in families and is more common in males than females - Kidd , 1984 ; Ambrose , Cox & Yairi , 1997 ; Felsenfeld, 1997 However, the exact percentage of occurrence in families and gender ratio is still not clear. These genetic studies assert biological predisposition towards children who are more likely to stutter. Keeping aside the complex ( confusing for a clinician) conclusions from the genetic studies , the clinician should expect that if there was a family history of stuttering , there is more likely a chance to impose a strong negative feeling about the disorder on the child . Such feelings need to be explored and discussed during the interview. This is important both in assessment and treatment.
5.
Evaluate the temperament and emotional stability of the child Most children these days have very low emotional tolerance and they are often hypersensitive.
This might be due to results of over protection and expectations on the child childs performance in any activity of interest to the parents.
Guitar (2006) also suggests that understanding the temperament of the child.
Increased physical tension during stuttering instances might be expected of a child due to his reactive temperament, and may lead to chronic stuttering.
A child with placid temperament may be more relaxed and will probably ignore / accept stuttering, thereby may outgrow / cope with the problem more easily.
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6.
Evaluate the three As of the concerned: awareness, anxiety and attitude towards stuttering. Awareness of the problem , anxiety that arises before , during and after stuttering spells and the attitude that one develops will reflect on the childs and the patients emotional reactions towards stuttering .
These emotional reactions may range from fear , guilt and embarrassment to complete helplessness and depression. These negative feelings need to be combated and analysis of the As will facilitated the unlearning of the fear based stuttering behaviors in the child.
When to evaluate? Evaluate as soon as the concern arises.
The concern may be raised by the parents, family and friends, school and the child him / her self.
The typical age at which the onset of stuttering is repeated is between two and four - Conture, 2001
70% of children with developmental stuttering have a gradual onset and nearly 50 75% improve without any formal treatment Guitar 2006 25 10/23/2013 KUNNAMPALLIL GEJO JOHN
Guitar also summarized the factors to be associated with the chances for natural recovery from stuttering, and they include the following:
1. 2.
Good language and phonological skills Good motor ( non verbal ) skills
3.
No family history of stuttering and natural recovery from it in the family members. Early age of onset and
Being a female.
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4. 5.
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Evaluation closer to the age at which the concerns arise is essential so that either intervention can be started or the parents can be asserted regarding spontaneous recovery.
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How and Where to evaluate?
For both clinical as well as research purpose, often times we would require to make categorical judgments regarding stuttering and fluent speech.
To arrive at this decision one necessarily need to conduct an interview and also observe the child, the concerned and their interactions and behaviors.
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Assessment using standardized tests like stuttering severity instruments (Riley) may be done.
Comparison with norm references may seem useful in occasions to diagnose, differentially diagnose and arrive at the degrees of severity of the problem.
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Case History Form:
Informs the clinician about:
The parents perception about the problem, at present

Its onset and development, and
The childs medical and family history and school history.
The first opportunity for the clinician to show her understanding about both the general nature of stuttering and the impact it can have on the child and his family.
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The first chance for her to: begin making the problems less mysterious, to respond to some of the myths or misinformation that the family may associate with the problem; to alleviate the feelings of guilt that usually accompany stuttering, and to begin to provide an overview about the direction of treatment.
The clinicians ability to orientate the family to the true nature of the problem may be the main benefit that the child and the family receive from the diagnostic meeting(s). - Contour (1997)
Parent Participation in Assessment: The motivation for initiating treatment may be minimal if the family physician or friends and family members suggest that the problem will likely go away by itself - Ramig, 1993c
The most important aspect of the interview process is the clinicians style and ability to be flexible and creative as she interacts with the parents. - Rustin & Cook (1995)
Talking more freely about stuttering directly with preschoolers, as well as with their parents may reduce parents distress about their childs stuttering; perhaps talking about stuttering openly reduces everyones fear on it. 32 10/23/2013 KUNNAMPALLIL GEJO JOHN
During parent interview, the clinician gives them an opportunity to talk about the matters that they feel and also the matter that they would like to share in confidence.
Clinician begin interview by letting parents know what he is going to do with them and their child during the remainder of the evaluation.
Clinician should assure them that, there will be a time for sharing the assessment information and recommendation with them at the end.
Usually during the assessment the clinician used to asks open-ended questions.
When parents have had a chance to describe the problem and appear to have no more to say at that moment, clinician should ask about the first stages of the childs life (the childs birth and development) and then work up toward the present time.
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In the ensuing conversation, the clinician should be sure that he/she gets information indicated by the questions which is mentioned below. 1) Were there any problems during pregnancy or the birth of the child? 2) What was the childs speech and language development like? How did it compare with siblings development and with your expectations? 3) Describe the childs motor development compared with that of his brothers, sisters or other children? 4) Have any other members of their family had speech and language disorders? 5) When was the Childs disfluency first noticed?
6)
Was anything special going on in the childs life when stuttering started? What was the disfluency like when it was first noticed?
7)
8)
What changes, if any, have been observed in the childs speech since stuttering was first noticed? Does the child appear to be aware of his dysfluency?
9) 10)
Does the child sometimes appear to change a word because he expect to be disfluent on it?
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11) Does the child seem to avoid talking in some situations, when he expects to be disfluent? 12) What do the parents believe caused the problem? 13) How do the parents feel about the childs disfluency problem?
14) What, if anything have the parents done about the disfluency problem? 15) Has the child been seen anywhere else for the problem? If so, what were the outcomes?
16) When and in which situations does the child exhibit the most disfluency? The least disfluency?
17) How does the child get along with his brothers and sisters and other children?
18) What is the childs personality and temperament like?
19) Is there anything else you can think of to tell us that will help us better understand your childs stuttering?
Child Interview Following questions can be ask during child interview.

1)
2)
Does the child think that he has any trouble talking?

How does the child describe the problem? When does it happen? What is it like at different times? Does he use any helpers or tricks to get words out? Does he avoid certain words? Are certain speaking situations more difficult? Does he avoid them?
3)
4)
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5) Does anyone ever tease the child about his speech? Who? How does he feel about it? How does he react?
6) How does the child feel about his speech?
7) How do the childs parents feel about his speech? What do they do when he stutters?
8) Ask the child, can you think anything else important for me to know about you or about the trouble you sometimes have when you talk?
PARENT-CHILD INTERACTION Clinician should observe one or both parents interacting with their child.
It is better to do this at the beginning of the evaluation for several reasons.

1.
Parents may be less affected by clinicians orientation toward stuttering and may thereby give the clinician more natural sample. This interaction gives clinician a chance to see the childs stuttering first-hand. Clinician can observe the way in which the parents interact with their child.
1.
1.
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The parent-child interaction can be done formally or informally.
Some clinician observe the interaction in the waiting room and make only mental notes
Some may visit the childs home
Some uses videotape recording of the parents and the child in the play style interaction in a treatment room supplied with toys and games.
CLINICIAN-CHILD INTERACTION
Here, the clinician can see directly what the childs disfluency is like, how he responds to various cues and to what extent the childs disfluency is modifiable. Always better to tape-record this interaction for later analysis. If videotape is available, it is preferable, since visual cues are sometimes critical in determining a childs developmental/treatment level.
Clinician focuses their interaction on toys or games suitable to the childs age.
Clinician should talk in an easy, relaxed manner much like they advice parents to do.
If the child is stuttering similarly to the way the parents have described, clinician keeps the same speech style throughout the interaction.
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However, if the child is entirely fluent or normally disfluent and the parents have described behaviors which a clinician feels are stuttering, clinician speeds up the speech rate and ask many questions.
Occasionally, clinician interrupt at some point to elicit the disfluent speech, which is perhaps more characteristic.
They do this to avoid misdiagnosing a child who is stuttering as a normally fluent speaker.
Talking about Stuttering: Prior to the clinician-child interaction, clinician try to determine if the child is aware of his stuttering. If the clinician thinks he isnt, then use only their observation in non-directive play to assess his speech.
If it is pretty clear, from earlier information or from clinicians own observation, that client is aware, then try to determine how able the child is to talk about his stuttering.
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This gives clinician an opening to go further and discuss his stuttering with the child.
Some clinicians will help a child talks about his stuttering by first telling the child about another child who stutters - Bloodstein, personal communication, 1990
In discussing stuttering with a child, clinician usually try to use their vocabulary such as getting stuck or having trouble on words.
In summary, the goals of these attempts to discuss the childs disfluencies with him are:
1.
To see if the child is accepting of himself and his disfluencies enough to discuss them.
2.
To indicate to the child that he is not alone with the problem and moreover we may be able to help them.
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A Child Who Wont Talk A very shy child may start to cry and along to his parents. In this situation, clinician talk with the parents in one part of the room while another clinician plays with the child in another part.
Clinician talk few minutes about general things, letting the child become familiar with the clinician with whom hes interacting.
Then clinician may suggest to the parents that we and they move into an adjacent room but keep the door open.
With this arrangement, clinician can usually talk about sensitive matters without being overheard. At times, certain children will separate from their parent, but wont interact with clinician during evaluation. Then avoid asking direct questions. Instead play with the child. After several minutes, clinician usually find that the child relaxes and begin to speak spontaneously. After this clinician can begin more direct interactions. Only after the child gets quite comfortable, clinician attempt to discuss his trouble talking.
A Child who is entirely Fluent Some children may be entirely fluent during the evaluation. In these cases, there are several options.
1.
The tape recording, that the parent sent the clinician, may have a good enough sample of stuttering to use it for speech sample.
1.
If the child is use a particularly fluent episode, clinician may reschedule him for evaluation at a later time.
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SPEECH SAMPLE
Usually, more than one speech sample i.e. a tape recording the parents have sent in, the parent-child interaction and the clinician child interaction.
Clinician choose the sample that has the greatest amount of stuttering for the most detailed analysis, but also note the extent of stuttering/fluency on the other samples.
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Assessing types, frequency and duration of dysfluency: Different types of dysfluencies can be identified as per Bloodsteins 1987 criteria: Repetitions:
1. 2.
Syllable repetitions - ma ma mattu Part word repetitions od od odthayidha
3.
4.
Whole word repetitions obba obba

Phrase repetitions
Pauses: Unfilled pauses silence longer than 300ms
Filled pauses pauses with extraneous sounds such as /a/, /m/ etc.
Prolongations: aaaaaaaaa aagaa Interjections: this well etc.
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Frequency of stuttering: Reported in %
No: of stuttered words/utterances in the analysed sample.

Sound and syllable repetitions within amultisyllabic word counted as iterations of a single repetition. e.g. /pe pe pe pen/ - one repetition and three iterations.
Percent dysfluency = total no: of dysfluencies/total no: of words * 100

Duration: Longer stutterings are worser than shorter ones.
An avg of the duration of the 3 longest blocks is a fair representation of the duration of the block.
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TO DETERMINE WHETHER OR NOT THE CHILD IS STUTTERING Eliciting Fluency Breaks:

During the assessment of the children, there will be occasions when the very behaviors, the clinician wants to observe and evaluate are not present.
On such occasions the clinician may choose to elicit these behaviors.

Essentially what clinician are doing is creating a speaking situation where temporarily, the demands we are placing on the child exceed his ability to use his speech production system.
For e.g. turn away as the child is describing an event or activity. Loss of listeners attention has long been known as a powerful technique for eliciting fluency breaks in children - Johnson, 1962, Van Riper, 1982
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The clinician may ask the child to respond quickly to a series of questions or ask him to answer somewhat abstract or difficult to answer queries - Guitar & Peters, 1980 Depending on the age of the child he or she could be asked to read from books that are somewhat above his grade level (Blood & Hood, 1978) Or Asked to describe a series of pictures which are presented at a rapid rate so that he is unable to formulate a complete response.
It is not necessary to elicit many of these breaks.
Once a few examples have been obtained, the clinician can consult with the parents to determine it these behavior they have observed and are concerned about.
Support for the importance of observing children in a variety of speaking situations was noted by Yaruss (1997a) in a study of 45 pre-school children undergoing diagnostic evaluation for stuttering.
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Frequency counts were obtained for both more and less usual disfluency types for each of the children as they took part in 3 to 5 of the following situation. Parent child interactions Play
Play with pressures imposed

Story retell Picture description
Results: These children who stuttered showed significantly more variability across the speaking situation than within any single situation. Children who produced a higher overall frequency of less typical disfluencies also exhibited greater variability. No significant correlation was found for the more typical fluency breaks. Finally, the play with pressure situation resulted in the greatest number of disfluencies, although this was not the case for all the participants, as many children exhibited highly individualized patterns.
Based on these results, Yaruss (1997a) suggested that sampling of a childs fluency in a single speaking situation is unlikely to result in a representative sample of behavior, particularly for children who exhibit a greater number of stuttering like disfluencies.
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The Nature of the Fluency Breaks Yairi (1997) recommends a speech sample of at least 500 syllables. The following guidelines are based on a per-100-syllable disfluency metric. Behavior 1. Total number of disfluencies per 100 syllables 2. No. of SLD per 100 syllables 3. Percent SLD to total disfluencies 4. No. or SER per 100 syllables
Preschool children who stutter Average of 16 Minimum of 3; mean of 11 Range of 60% to 75% Mean of 6 to 8
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Behavior 5. No. of units per instances of SER 6. Percent of SER containing two or more extra units. 7. No. of SER containing two or more extra units per 100 syllables 8. Percent of disfluencies occurring in clusters
Preschool children who stutter Mean of 1.5 Mean of 33% Mean of 3 Mean of 50%
9. No. of disfluencies per cluster

10. No. of face and head movements per disfluency 11. Duration of disfluencies in msec 12. Duration of interval between repetition units 13. Proportion of silent interval to total duration of SER containing one extra unit
Mean of 3
Mean of 1.5 to 3 Mean of 750 Mean of 200 msec Mean of to 1/3
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Conture (1997) also suggests that clinicians consider a number of subtle signs that may help to distinguish the possibility of stuttering.
1.
Within-word disfluencies that average 3 or more per 100 words (minimum of 300 word sample) Sound prolongations in 25% or more of the childrens No. of fluency breaks. An average differences of two or more syllables per second in speaking rates of the mother and children during conversational speech, increases in the occurrence of simultaneous-talk by the child and parent, and greater amounts of parent-child interrupting behaviors.
2.
3.
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4.
The presence of stuttering, stuttering clusters in the childs two element speech disfluency clusters. Eye ball movements to the side, eye blink during stuttering or both. Clusters of two or more within-word breaks on adjacent sounds, syllables or words within an utterance.
5.
6.
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DETERMINING A CHILDS LEVEL OF ANXIETY ABOUT SPEAKING Two types of anxiety have been identified and have been the focus of research.
1.
Trial anxiety has to do with the persons general level of
anxiety
Obtained by having the client respond to self-report scales containing questions about how he or she generally feel.
2.
Measures of state anxiety are intended to indicate a measure of a persons anxiety response at a specific moment as he or she react to specific situational stimuli.
A frequently used measure of anxiety is the state-trait anxiety inventory for children (STAIC)
Developed by Spielberger, Edwards, Montuori, Luschene, and Platzek (1972).
Score on both State & Triat sub-scale range from 20 to 60, with high score representing greater anxiety.
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Using the STAIC, Craig & Hancock (1996) found no significant differences between 96 untreated children who stuttered and 104 children who did not stutter (age range 9-14 years).
In addition, the authors found no significant association between stuttering frequency and state anxiety.
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Determining the Likelihood of Chronicity Assuming that the young childs fluency breaks are considered to be unusual or abnormal, the next clinical decision is whether this pattern is likely to continue developing. However, the seventy of the overt stuttering does not always predict whether or not the child will recover. Nonverbal 8 years of struggle in the term of eye, head or general body movements may also indicate the need for intervention. However, if these signs are less evident, the best clinical choice is questionable.
A family history of stuttering and the parents concerned response to the childs disrupted fluency may suggest intervention as the clear choice.
Parental judgement of a childs speech difficulty should be considered a fundamental part of a diagnosis of stuttering - Conture & Caruso, 1987, Onslow 1992, Riley & Riley 1983
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On the other hand, if there is no family history of stuttering and parents and other caregivers are unconcerned about the childs speech
To monitor the child for approximately 3 months
Yairi, Ambrose & Niermann (1983) suggest that there is a tendency for children to recover within 3 months following onset.
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Stuttering Severity Index (SSI) Standard sample of the childs speech is require to analyze with Rileys SSI.
Riley suggest that any child below third grade should be asked to describe a set of pictures to provide a sample of 150 words for analysis.
The child may also be engaged in conversation, and if this sample shows more stuttering than the picture description, it should be used for the analysis.
Clinician typically use a 5 minute sample, rather than a 150 word sample, because it is easier to ensure that we have a complete sample.
Frequency of stuttering, mean duration of the three longest stutterings and physical concomitants are scored and the total is computed.
The total score permits a labeling ranging from very mild to very severe.
Speech Rate Clinicians assess the rate of childrens speech using the speech sample obtained for the SSI. Speech rates for three age groups of non-stuttering preschoolers have been obtained by Rebekah Pindzola, Melissa Jenkins & Kari (1989). Children in their study were asked a series of questions from the Developmental Learning Materials Picture Cards and rates were obtained in syllable per minute (SPM) only. Their sample consisted of 6 males and 4 females in each of 3 age groups. 76 10/23/2013 KUNNAMPALLIL GEJO JOHN
They found: for 3 year olds - 116-163 SPM
for 4 year olds - 117-183 SPM

for 5 year old - 109-183 SPM. Differences between age group were not statistically significant, and no comparisons between males and females were made. Data on words per minute are not available.
Diagnosis/differential diagnosis:
2% dysfluency or 5% dysfluency cut off criteria for differential diagnosis.
A child having more than 2% or 5% dysfluency is diagnosed to have stuttering.
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Whatt nexttttt?!?!?!??
Create a profile based on the observations and assessment. Decisions
Child naturally recovering from the difficulty
Needing intervention
Normal non fluency

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Different levels of stuttering

Diagnostic labels ascertain our decisions and to facilitate understanding of the nature of the childs problem. Earlier, labels more descriptive of the severity based on norms Current trend based on the behavioral profile indicates the developmental levels of stuttering
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Conclusions: Assessment of stuttering involves:
Judgements of the listeners in making decisions about the type frequency duration and associated manifestations o the disorder. Never attempt to remediate children with stuttering before gaining a good idea of the childs capacities and the concerns of the parents
Prevention of relapse, and effective treatment would be possible only with a comprehensive, complete and continuing assessmentKUNNAMPALLIL of the stuttering behavior. 81 10/23/2013 GEJO JOHN
Assessing Fluency Disorders in Adults The most fundamental goal during the initial period of assessment is to understand the clients story. How a person tell his story reveals important characteristics of the person and his problem.
The client may well have experienced previous treatment and know something about basic terminology concerning stuttering.
He may have some insight about the therapeutic process.
At the other extreme, a new client may know absolutely nothing about the true nature of stuttering and depending on his cultural background and educational experience, bring with him a basket of myths often associated with the disorder. While some people have a degree of inquisitiveness and openness about their problem, others will indicate embarrassment and shame. Our task is to find out where they are on their journey of change, their understanding of their situation and their willingness to enter into the hard work of making change happen.
Generally, although not always, both the surface and the deep structure of stuttering are more severe and more obvious in adolescent and adult speakers.
Even at the early stages of stuttering development, some young children will display well-developed tension (sound prolongation and body movements) and fragmentation (within-word fluency breaks) which are typically associated with advanced or established stuttering - Schwartz & Conture, 1988; Yairi 1997
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Usually however, older speakers show much greater complexity of behavior and exhibit greater anxiety and fear.
Adolescents and adults have coped and adjusted to the problems for years.
Thus, the features of their stuttering, especially those having to do with concealing the problem, tend to be more sophisticated and complex.
Begin by welcoming the client and explaining what procedures will be used to evaluate his problem videotaping and audio taping of his speech, questions about his past and current difficulties and question about his feelings and attitudes regarding his speech.
This followed by analysis of the information and a concluding interview in which the diagnosis will be shared with the client and discuss the things that can be done about his problem.
Begin the interview with an open ended question.

Speech Sample Pattern of Disfluencies
Throughout evaluation of the adult or adolescent stutterer, clinician observe the pattern with which the client stutters.
Clinician try to determine for e.g. roughly what proportion of the core behaviors are repetitions, prolongations and blocks.
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During blocks, where and how does the stutterer shut off airflow or voicing?
What are the clients escape and avoidance behaviors?
Is this client able to tolerate being in a block, or does he speak in an unusual or vague way to avoid stuttering?
This information will be useful when the clinician help the client reassess more about his stuttering and help him decrease his fear of it. 88 10/23/2013 KUNNAMPALLIL GEJO JOHN
Speech Rate Rate often reflects the severity of stuttering and the effect it as having on his communication.
If the clients speech rate is markedly below normal, communication may be difficult for him.
Rate can be measured as either words per minute or syllable per minute, depending on the clinicians performance.
Some clinician find it easier to calculate rate using words per minute, because words are easily observable units.
Others note that syllables per minute can be calculated more rapidly than words because the clinician can use the beat of the syllable to count on-line (i.e. while the speaker is talking).
The syllables per minute approach also allows for the fact that some speakers will use more multisyllable words than others.
Speakers who use many polysyllabic words might otherwise be penalized because their words may take longer to produce than those who speak using mostly one-syllable words. No matter which method is used, the following rules can be used for counting words or syllables:
1.
count only the words/syllables that would have been sound if the person had not stuttered.
Thus, if the person says My-my-my, uh well my name is Peter, this should be considered as 4 words or 5 syllables, because it would be assumed that the extra mys and the uh are part of stuttering.
If a person says, when I went to Boston, I mean when I went to New York and it does not appear that the person was postponing or using any other trick to avoid stuttering, this would be counted as 13 words or 14 syllables, because the persons stuttering did not interfere with the utterance.
Only words (or syllables in words) are counted uh or um are not counted.
Oh or well are counted, unless they are used as a postponement, starter or other component of stuttering.
The rate of speech is can be calculated by asking the case read a std passage whose syllable count is known.
The time taken to complete the passage is noted.
Rate - The total no: of syllables/total time taken
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Analysis of core behaviors and determining severity: Hegde and Davis, 1992 give a description of the major dysfluency types:
1.
Repetitions: Part word Whole word - What ta-ta-ta-time is it? - What-What are you doing?
Phrase
- I want to- I want to- want to do it
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2. Prolongations: sound/syllable prolongations - Lllllllllet me do it.
Silent prolongation
3. Interjunctions: Sd/syllable - Um-Um I had a problem this morning Whole word - I had a Well problem this morning Phrase
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- I had a you know problem this morning

Silent pauses Broken words
Incomplete phrases
Revisions Dysfluency Index (DI): Total no:of dysfluencies/ Total no: of words * 100
Indices for each of the stuttering type can also be obtained.

Percentage syllable stuttered (PSS): Total syllables/ Stuttering * 100
Durational indices: pause time, total articulatory time, fluent articulatory time, stuttering time percentage.
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Stuttering Severity Index: Given by: Savithri & Jayaram, 1993

A)
Average syllable emission rate (ASER):
ASER = FSER DSER, Where, FSER = Total no: of syllables uttered during dysfluent phase/ Total duration of dysfluent phase DSER = Total no: of syllables uttered during fluent phase/ Total duration of fluent phase
B) Stuttering instances: PSI = Total stuttering moments/ Total syllables uttered * 100 C) Product of Multiple repetitions: PMR = OMR x AI,
Where,
OMR = Total no: of multiple repetitions/Total no: of syllables spoken * 100 AI = Total no: of iterations/ Total no: of multiple repetitions * 100 99 10/23/2013 KUNNAMPALLIL GEJO JOHN
D) Duration of stuttering instances: ADS = Duration of all stuttering instances/ Total no: of stuttering instances. SSI= ASER + PSI + PMR + ADS
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Assessment of motor behaviors: Assessment of prosodic features:
Assessment of self rating of stutterers:

Modified S- scale for self evaluation of stutterers
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Assessment of Articulation, Phonation, Respiration: Hard articulatory contacts for plosive sounds
Misarticulations
Substitute voiced and unvoiced sounds with each other.
Laryngeal miscoordination
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Santosh, 2007 identified errors in articulation by spectrographic analysis:

1. 2. 3. 4.
Addition of vowels Addition of clicks Errors in place of articulation Errors in manner of articulation
5.
Errors in place and manner of articulation
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Baverly, 1987 identified delayed phonatory onsets, hard glottal attacks, pitch breaks, excessive pitch variations, too loud and too soft phonations. Respiratory features : shallow breathing, audible inhalation, prolonged inhalation, gasping and a rhythmical breathing.
Aerodynamic errors identified by Santosh, 2007

Production of aspirated phonemes for unaspirated and vice versa Inspiratory intake between or within words
Instrumental evaluation of stuttering:
EGG, Spectrography
Glottogram at the moment of stuttering - glottal gestures during stuttering
Chevire-Muller, 1963 used EGG and acoustic data and reported irregularities including hard glottal attack and clonic flutter in VFs.
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Mohan Murthy, 1988 using EGG, electroaerometric and audio signals showed that stutterers had atypical transitions, inappropriate duration of segments, inappropriate voicing, inspiratory frication, and abnormal articulatory constraints. Santosh and Savithri, 2005 analysed speech of 6 stutterers using a wideband spectrogram.
Seven abnormal behaviors were reported.
Stutterers used partial voicing
Partial voicing for unvoiced units

Open glottal gesture with cessation of voice.
Used an airstream characterised by low frequency murmrur instead of voicing. A murmured plosive substituted for voiced phoneme.
Unvoiced for voiced Voiced phonemes in place of partially voiced sounds.
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Diagnosis/ Differential diagnosis:

Neurogenic Stuttering
Psychogenic stuttering
sis
Cluttering
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Assessment of stuttering Take case history interview Obtain a representative speech sample Analyze core speech behaviors Determine the severity of stuttering by scales and indices Assess prosodic features and rate Assess associated motor behaviors
Assess the articulation, phonation, and respiration

Assess the self rating of stuttering
Summary: Evaluating a client who may stutterer or clutterer (fluency disorders) our task is to decide:
1. 2.
If his disfluencies warrant treatment. What are the important characteristics of his history, current environment, speech behaviors and reactions. What treatment do these characteristic indicate.
3.
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Most of the tools might answer these three questions, but the most critical is our judgement. Whether the person is to be treated as a normally speaker or having fluency disorders depends on interpretation rather than a score. We must weigh what we see and hear about his behaviors to determine if they indicate stuttering, normal disfluency or any other disorders. One of the flood of information we gather, we must distill the essential characteristics that lead to a choice of treatment.
REFERENCES: Kenneth, G.; Shipley, and Mc Afee, J. Communicative Disorders: An Assessment Manual, Chapman and Hall, London, 225-255. Manning, H.W. (2001). Clinical Decision Making in Fluency Disorders.Singular; Thompson learning Conture, E.G. (2001). Stuttering: Its nature, diagnosis, and Treatment. Boston: Allyn & Bacon. Wingate, M.E. (1962). Evaluation and Stuttering, part III: Identification of Stuttering and the use of a label. Journal of
Speech and Hearing Disorders, 27:368-377.
Guitar, B. (2006). Stuttering: An integrated Approach to its Nature and Treatment (ed.3.). Baltimore: Lippincott Williams & Wilkins Bloodstein, O. (2002). Early Stuttering as a type of language difficulty. Journal of Fluency Disorders, 27:163-167.
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Assessment of Fluency Disorders. / KUNNAMPALLIL GEJO JOHN

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Assessment of fluency disorders

KUNNAMPALLIL GEJO JOHN, MASLP

KUNNAMPALLIL GEJO JOHN

speakers effortless flow of speech.

KUNNAMPALLIL GEJO JOHN

KUNNAMPALLIL GEJO JOHN

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REASONS FOR THE EVALUATING SPEECH FLUENCY

GOALS OF THE ASSESSMENT

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Initial Contact Case history form

Hearing Speech samples Fluency

Which one is it?

Stuttering like Dysfluencies?

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Evaluation and description of the dysfluency of the child:

Voice aspects during stuttering instances

Intelligibility of speech KUNNAMPALLIL GEJO JOHN

Describe the developmental history ( speech and language )

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Track the pedigree

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When to evaluate? Evaluate as soon as the concern arises.

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How and Where to evaluate?

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Case History Form:

Informs the clinician about:

The parents perception about the problem, at present

The childs medical and family history and school history.

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18) What is the childs personality and temperament like?

Child Interview Following questions can be ask during child interview.

Does the child think that he has any trouble talking?

6) How does the child feel about his speech?

It is better to do this at the beginning of the evaluation for several reasons.

The parent-child interaction can be done formally or informally.

Some may visit the childs home

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Syllable repetitions - ma ma mattu Part word repetitions od od odthayidha

Whole word repetitions obba obba

Pauses: Unfilled pauses silence longer than 300ms

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Frequency of stuttering: Reported in %

No: of stuttered words/utterances in the analysed sample.

Percent dysfluency = total no: of dysfluencies/total no: of words * 100

Duration: Longer stutterings are worser than shorter ones.

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TO DETERMINE WHETHER OR NOT THE CHILD IS STUTTERING Eliciting Fluency Breaks:

On such occasions the clinician may choose to elicit these behaviors.

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It is not necessary to elicit many of these breaks.

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Play with pressures imposed

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9. No. of disfluencies per cluster