Assessment of Fluency Disorders
Stephen Tasko
Speech Pathology and Audiology
Western Michigan University
What is a fluency disorder?
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Stuttering
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Developmental stuttering
Psychogenic stuttering
Neurogenic stuttering
Cluttering
(Developmental) Stuttering
Common Features
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Breakdown in the fluidity and rhythm of speech
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Breakdowns include
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Sound repetition
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Audible and silent prolongations
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Typically occurs at the beginning of utterances
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May fluctuate a great deal across situations
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Stuttering influenced by environmental, linguistic and other communicative
pressures
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May delay (postpone) or avoid saying certain words/sounds etc
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Can have associated symptoms including overt body movements such as
facial twitches, grimaces, head jerking, extraneous limb movement etc
(secondary behaviors)
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Can have associated symptoms of anxiety, shame, fear and guilt
(Developmental) Stuttering
Natural 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
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Prevalence: roughly 1% of population
Lifetime incidence: ~ 4-5 %
In developed form, expectancy, fear and avoidance
play significant roles
(Developmental) Stuttering
Who 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 Stuttering
Neuropathology
 Distinct from aphasia,
dysarthria, apraxia
 Observed following lesions
to
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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 fluencyenhancing conditions
Psychogenic Stuttering
Stuttering secondary to emotional trauma or
stress
Some 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
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Cluttering
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Daly, 1992
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“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)
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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 (%)
93
90
83
83
82
82
80
80
78
75
Stuttering vs. Cluttering
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Pure cluttering considered relatively rare
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Is it rare or do pure clutterers not seek treatment?
Cluttering-stuttering more common
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Clinical reports of about 1/3 of youngsters who
stutter show signs of cluttering
The Assessment Process
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Case History
Evaluating Attitudes Toward Problem
Evaluating Stuttering Behavior
Diagnostic Probes
Summarizing and Making Recommendations
General Considerations
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Build rapport
Age
Audiotape session (videotape if possible)
Case History
Problem Description
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General
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What is the problem?
Why is this a problem
Specific
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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
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History
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When did it start?
Who identified it?
Why do you think it started?
Summarize the history of the stuttering.
Problem Description continued
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Family history of stuttering
Medical history
Pregnancy
Family constellation
Developmental information
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Speech and language
Intellectual
Physical
Emotional
Problem Description continued
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Attitudes Toward the Problem
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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
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A-19 Scale for children who stutter
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Revised Erickson scale
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Original items drawn from MMPI
24 T-F items with normative data
Perceptions of Stuttering Inventory (PSI)
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19 Y-N questions
60 questions
3 themes, struggle, avoidance, expectancy
Children’s attitude test
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35 T-F questions
Older children can self administer, younger children can be asked
questions
Additional Information
Self rating of problem
 Overall
 How representative is speech today?
Therapy history and attitudes toward therapy
 Therapy history
 Expectations of therapy
Evaluating stuttering behavior
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Counting and sorting disfluencies
Physical descriptions of disfluency
Stuttering instruments
Noting associated behaviors
Counting and Sorting Disfluency
Types 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
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Physical description of disfluency
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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 disfluency
Physiologic 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. stuttering
Common 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 youngsters
During 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
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Family history
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Concomitant speech/language
issues
Duration
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Positive family history
Speech language status
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male
>14-18 mos.
Age of onset
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Onset after 3.5 yrs
Speech Samples
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Reading aloud
Picture Description
Monologue: Job Description
“Problem” areas (e.g. telephone)
Variables known to influence fluency
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Automatic speech
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Choral speaking
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Use difficult material
Altered speech rate
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Use difficult material
Whispered speech
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Counting
Say it fast/slow
Applying stress to client
Associated Behaviors
Selected Test Instruments
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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)
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Provides a percentile rank and “severity”
rating based on a composite of scores based
upon
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Frequency of disfluency
Duration of disfluency
Presence of physical concomitants
Measurements based on
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Spontaneous speech and reading when literate
Picture description if not literate
Overall Assessment of the Speaker’s
Experience of Stuttering (OASES)
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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)
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Four content areas
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Section I: General Information
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Section II: Your Reactions to Stuttering
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Assesses the client’s situational difficulties (work, social, home)
Section IV: Quality of Life
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Assesses the affective, behavioral, and cognitive reactions to stuttering
Section III: Communication in Daily Situations
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Assesses self-perception of impairment, fluency, speech naturalness
Assesses knowledge about self-help and treatment options.
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)
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Developed to measure
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Frequency
Intensity
Duration
Postponement/avoidance
Provides a profile that is well suited for
evaluating therapy progress
Diagnostic Probes
Summarizing and Making
Recommendations