Stuttering Assessment Principles & Procedures PDF

Stutterin g Assessment Principles and Procedures 1 Today’s Learning Outcomes: To understand principles underpinning assessment of stuttering population To understand the importance of client-centred assessment To understand that ass...

Stutterin g Assessment Principles and Procedures 1 Today’s Learning Outcomes: To understand principles underpinning assessment of stuttering population To understand the importance of client-centred assessment To understand that assessment informs prognosis and therapy progress as well as diagnosis To balance holistic and focused assessment practice To develop skills in administering standardised and non-standardised assessments. 2 Summary of last session What did you learn?  The experience of stuttering  The impact of stuttering  Theories of stuttering  A ‘one size fits all’/ ’cookie cutter’ approach to intervention is not appropriate 3  Assessment Preliminaries (Guitar 2014) Information-gathering Be aware Personal-encounter Be a scientist Bias Be a humanist Case history Judgements Establish trust Gather speech sample Assumptions (positive or Establish empathy negative) Clinical observations Establish accepting Analyse and interpret atmosphere Engage in active listening 4  Consider educating PHN’s, GP’s, teachers etc in identifying children at risk of persistent stuttering New tool soon to be available: Childhood Referral of children Stuttering Screener for Physicians (CSS-P) (Check: who stutter to SLT Stuttering Therapy Resources - Helping SLPs Help People Who Stutter ) Importance of early intervention to increase likelihood of ‘recovery’ and also to minimise the negative impact stuttering has on individuals if it persists. Comprehensive Assessment of Stuttering 6 Assessment of Child who Stutters (CWS) Comprehensive assessment acknowledges all aspects of stuttering (overt and covert) Includes a thorough case history Consideration of child’s environment: parents, significant other, teacher etc Consideration of motoric, social, emotional, cognitive, and linguistic demands  Informs a profile, severity rating, prognosis 7  Guitar, 2014: Normal disfluency v stuttering Understand the stutter (%SS, types, severity, speech rate) Assessment Understand feelings/attitudes/avoidance Principles Understand impact within self/home/school environments  The SLT selects diagnostic instruments applicable to the client’s profile Full speech and language assessment required with thorough analysis to guide overall management. Information is obtained from all relevant environments 8 9  Aims Listen and understand parent perspective Initial Parent Obtain preliminary information Contact Answer initial questions (Goal: educating and supporting parents) Convey interest and acceptance (Guitar, 2014) Explain origin and nature of stuttering Describe assessment process (case history etc) 10  Ask open-ended questions/listen to concerns Only then proceed to follow-up questions Onset and development Child’s reactions Family’s reactions Convey acceptance and interest Meeting School: with Parents does s/he like it? Does speech bother them there? Participate less in school? Teasing or bullying? Stuttering more at school than home? Previous therapy? Has it helped? In what way? Did he like it? 11  Clinical Qs During Initial Contact (Pre-school child) According to Kelman & Nicholas (2008), if the answer is yes to any of the following a child is at risk for persistent stuttering.  Is there a family history of stammering?  If so, did the stammering persist into adulthood?  Are the parents worried about the child’s speech?  Has the child been stammering for more than 12 months?  Has the stammering stayed the same or become worse?  Does the child have any other speech/language difficulties?  Has he had any other speech and language difficulties in the past?  Are his language skills advanced?  Is the child aware of his stuttering?  Is the child worried about his speech? (Kelman & Nicholas, 2008: 35) 12 Case History Recommended case history forms: Kelman & Nicholas (2008) (Palin PCI); Guitar (2014) Both versions look for information on: Background information including details of family life Developmental history The onset and development Communication skills and relationships Medical history Eating and Sleeping Personality Genetics Education Behaviour management 13 Child’s Perspective Gaining the child’s perspective provides information on their level of awareness and the level of impact. Importance of rapport Speak generally – hobbies, likes/dislikes Once child is comfortable, discuss speech “Do you know why you have come to SLT?” “Sometimes children have trouble getting words out. Their words just seem to get stuck” (use silence)  It aids rapport as SLT may begin using the child’s wording when talking about stuttering e.g. ‘getting stuck’, ‘bumpy’ etc.  It begins the therapeutic process of identification and desensitisation. 14 Child’s Perspective Resources Both Palin PCI manuals (Kelman and Nicholas, 2008; 2020) – The Child’s Perspective (Child assessment booklet/Appendix IV) Guitar, 2014 (p 200) 15 16 Home Environment Information about home environment to be collected using detailed case history form, and through discussion with parents and with child. Information about the home environment may be disclosed throughout the therapy sessions and not exclusively at the initial assessment. Important to facilitate a non-judgemental environment for parents and children to support their disclosing of personal information. 17 Assessment of Environmental Factors Palin Parent Rating Scales (Palin PRS) 19 items looking at: 1) Parents perception of stuttering impact 2) Parent’s perception of severity and impact on parent 3) Parent’s stuttering knowledge and confidence in management. Free online resource: https://www.whittington.nhs.uk/def ault.asp?c=28941 18  https://view.officeapps.live.com/op/ view.aspx?src=https%3A%2F %2Ffiles.constantcontact.com %2Fcd365c81401%2F964deb54-b688-42c7- 8132-afc4a8bd788e.docx%3Frdr %3Dtrue&wdOrigin=BROWSELINK 19 Family Interactions  A/V recording is essential for assessment of family interactions.  The family is recorded in the clinical context but outside recordings are possible to include.  PCI (Kelman & Nicholas, 2008) use a checklist to chart the presence or otherwise of interaction strategies and also chart the necessity of facilitating change in current interaction strategies. ◦ Example:  Following child’s lead in play  More comments than questions  Language appropriate to child’s level  Use of eye contact etc (Kelman & Nicholas, 2008) 20 Advice Sheets for Parents 21  Preschool/School Teacher Liaison Phone call/school visit/teacher attending SLT Empathy: Teacher’s have busy workloads and responsibilities May not understand or know how best to help Exchange of information: Offer advice and seek information Teacher’s Assessment of Student Communicative Competence (TASCC; Smith McCauley and Guitar, 2000): examines communicative functioning in an educational context 22 Exercise 1 Group Work: Consider what questions an SLT could ask a teacher to gain information about the child’s stuttering in school. 23 Preschool/School Teacher Liaison Does s/he talk in class? Does s/he stutter? What is the stuttering like? Does stuttering impact school performance? Is there a difference oral and written performance? How do other children react to the stuttering? Any teasing/bullying? How does teacher react? 24 Note: Any recommendations/advice sheets should be tailored to the individual child’s needs. This may be achieved through prior agreement with child or parent on what best supports them in school. 25 26 Assessmen t of Personal Stuttering is variable by nature: speech sample may/may not Factors be representation of functional speech Check with parent/client whether sample is representative A speaking sample of 300 to 400 syllables is best practice Behavioural (Guitar, 2006; 2014). Kelman & Nicholas (2008): Auditory/video recording for reactions: fluency analysis e.g. 10 What’s Wrong pictures. Speech Stuttering frequency, type of stutter, rate of speech (Kelman & Nicholas (2008) Disfluencies A reading sample often gives insight regarding the extent of word avoidance being used by the client. 27 Remember: Typical Disfluencies The following are not considered to be types of stuttering but typical disfluencies. ◦ Interjections e.g. ‘..am...um...eh..’ ◦ Phrase repetitions e.g. ‘Mammy, David took my-took my-took my DS’ ◦ Multi-syllabic whole word repetitions e.g. ‘because- because’, ‘walking-walking’ ◦ Phrase revisions/abandoned utterances e.g. ‘The DS with the blue-with the pink Pokémon is mine’ 28 %SS Calculation  Step 1: Calculate the total number of syllables spoken  Step 2: Calculate the total number of syllables stuttered  Step 3: Calculate percentage No. of syllables stuttered X 100 = %SS No. of syllables spoken 29 %SS Analysis 1. Listen to the whole sample and count no. of syllables spoken 2. Listen for stuttering moments – categorise and note how many Note points of longer stuttering moments 3. Listen for normal dysfluency and categorise 4. Note the duration of the three longest stutters 5. Note clinical observations of any secondary behaviours 30 What to count as an episode of stuttering (Palin PCI) What to count as an episode of stuttering? Single syllable whole word repetitions (e.g. but-but-but) Part word repetitions- sound or syllable (e.g. b-b-b-but) Sound Prolongations (e.g. m:ummy; mu:ummy) Blocking What not to count as an episode of stuttering? Multi-syllabic whole word repetitions e.g. ‘because-because’ Interjections e.g. ‘she is um cooking’; I don’t like uh uh carrots’ Phrase repetitions e.g. ‘I want I want that one’ Phrase revisions/abandoned utterances e.g. ‘I go to sch- I go to nursery’ 31  Transcribing Indicate on your transcriptions the type of stuttering and the number of episodes/approximate duration Stammering Type Transcription Analysis SSt SSp Repetitions Where-where-where-where 3 reps 1 1 SST: Syllables p-p-pencil 2 reps 1 2 stuttered. Prolongations w:ind 0.5 seconds 1 1 SSP: Syllables stro:ng 3 seconds 1 1 spoken. If observed increase in intonation 3 seconds 1 1 stro: †ng Blocks (m)y 4 seconds 1 1 (of sound or airflow) (Kelman & Nicholas, 2008) 32  *Count every syllable Practice time spoken except the repeated syllables in an episode of stammering. Transcript S. Sp. S. St. Um my-my-my name is Andrea When I was at hurling training I mean rugby training I um s:lipped and hur:t my (a)nkle. Mu-mu-mu-mu-mummy, Rachel came out rea:lly fast and-and-and- and-and she hit m:y arm! Do you bemember remember when I was small and I had a bottle? The c-c-c-c-candle is bwo:ken 33  Answer Time Transcript S. Sp. S. St. %SS Um my-my-my name is Andrea 6 1 When I was at hurling training I mean 21 3 rugby training I um s:lipped and hur:t my (a)nkle. Mu-mu-mu-mu-mummy, Rachel came 14 4 out rea:lly fast and and-and-and-and she hit m:y arm! Do you bemember remember when I 18 0 was small and I had a bottle? The c-c-c-c-candle is bwo:ken 6 2 34  Answer Time Transcript S. Sp. S. St. %SS= Um my-my-my name is Andrea 6 1 10/65= 15% When I was at hurling training I mean 21 3 rugby training I um s:lipped and hur:t my (a)nkle. Mu-mu-mu-mu-mummy, Rachel came 14 4 out rea:lly fast and and-and-and-and she hit m:y arm! Do you bemember remember when I 18 0 was small and I had a bottle? The c-c-c-c-candle is bwo:ken 6 2 35 Speech Disfluency Count Sheet in appendices 36 Clinical Observations: Physical Previously called secondary tension/struggle/movement behaviours Now considered to be part of stuttering and not secondary Includes  facial tension  body movements  disrupted breathing (Kelman & Nicholas, 2008) (appendix V) Behavioural reactions (Tichenor & Yaruss 2019) Movement in arms, legs, hands Muscle tension (this may or may not be overt) Closing eyes/looking away 37 Rate of Speech Observe rate of speech of child and parent Rate of child or parent’s speech may contribute to stuttering episodes An important measure if making a differential diagnosis between stuttering and cluttering. Cluttering may occur alongside stuttering Remember: Cluttering 38 Calculating Stuttering Severity  The SSI-3 (Riley, 1994) and SSI-4 (Riley, 2009) provide norms for calculating severity:  Frequency  Duration  Physical Concomitants  Naturalness of speech  In the absence of this test, what can be done? 39 40 Calculating severity Use a severity rating scale 1. Yairi & Ambrose (2005) have an 8 point severity rating scale ranging from 0= normal speech to 7 = very severe stammering. 2. The Lidcombe Program’s Severity Rating Scale (Onslow, Costa and Rue, 1990) used by parents and clinicians (1- 10) 3. Severity Rating Scale (Guitar, 2006; 2014) Any problems with the use of these scales? Who is making the judgement? Are these scales considering the totality of stuttering? 41 42   Avoidance behaviours may be observed or described.  They begin as a reaction to feeling of being Behavioural stuck/loss of control in an attempt to either end or avoid stuttering Reactions:  Conditioning over time results in these reactions becoming an integral feature of the stutter. Avoidance  Avoidance of words (e.g. word substitution); activities (e.g. answering phone); participation (e.g. playing with friends) etc. 43 Affective/Cognitive Reactions School-Aged Children Overall Assessment of the Speaker’s Experience of Stuttering: OASES- School Aged (Yaruss & Quesal, 2008) Communication Attitude Test (Brutten and Dunham, 1989) Research indicates successful differentiation between non-stuttering children and CWS (DeNil and Brutten, 1991) A-19 Scale (Guitar and Grims, 1977) Obtains information on attitudes to speaking 44 Reactions to Stuttering Clinical observations during assessment is essential to informing clinical decisions regarding sensitivity to stuttering. The client’s reaction to their own stuttering including loss of eye contact, blushing, self-conscious movements, whispering etc. Parents’ reactions to their child’s stuttering and the parents’ sensitivity to stuttering e.g. Ability to use word ‘stuttering’/’stammering’; language used to describe incidences, willingness to liaise with relevant professionals and discuss stammering openly with the child. 45 1. Communication Attitude Test 2. Behaviour Checklist 3. Speech Situation Checklist – Speech Disruption 4. Speech Situation Checklist – Emotional Response (Brutten and Vanryckeghem, 2007) *KiddyCAT for Preschool Children/Under 6 years 46 47  Overall Assessment of the Speaker’s Experience of Stuttering (OASES) Yaruss & Quesal 2006  Evaluates the experience of stuttering from the perspective of individuals who stutter.  Based on the WHO ICF  Collects information on: (a) general perspectives about stuttering (b) affective, behavioral, and cognitive reactions to stuttering (c) functional communication difficulties (d) impact of stuttering on the speaker’s quality of life.  Child, adolescent and adult assessments  Activity limitations and participation restrictions can also be identified using case history and conversations with child and parents. 48 Multiculturalism (Ogundare, 2012) Be aware of multicultural issues associated with stuttering E.g. Some African Americans believe stuttering is caused by a child being tickled too much, looking into a mirror as a baby etc. Importance of educating families (and AWS) on the nature of stuttering and its origin SLT should ask sincere questions and be non-judgemental in their listening Honest communication will lead to meaningful rapport (may encourage client to disclose information pertinent to therapy) Multicultural Stuttering and Treatment: A Cross Cultural Analysis https://opensiuc.lib.siu.edu/cgi/viewcontent.cgi?referer=https://ww w.google.com/&httpsredir=1&article=1369&context=gs_rp 49 Simulated Practice Group 1: CAT (BAB) Group 2: Palin Parent Rating Scale (PRS) Group 3: OASES Group 4: Stuttering Severity Instrument (SSI-3) What aspect(s) of stuttering does the test assess? Are there gaps? Consider pros; consider cons What could supplement? 50  Consider totality of stuttering experience Detailed case history Summary of View stuttering in context of child and their environment (e.g. busy household, siblings, anxiety-inducing events, Child sleep, etc) Recording of child’s speech for full analysis (%SS, type Assessment etc) Recording/observation of child/parent interaction Analyse speech for SLDs and TDs Full speech and language assessment essential Observe social communication skills (listening, turn- taking etc) Multi-disciplinary approach required (teachers, psychologist, audiologist, OT etc) 51  Assessment of Adolescents/Adults 52 Assessment of Adolescents/Adults Assessment is guided by the adult’s individual goals of intervention e.g. if the goal is increased fluency- use speech assessment; if goal is increased participation in society-use OASES for e.g. Full case history is recommended prior to assessment (Adolescent and Adult case history forms: Guitar 2006; 2014) Listening to the adults lived experience of stuttering is important part of assessment Fluency is frequently desired goal. Important to discuss that increased fluency may not remove negative cognitions and emotions associated with communication. Therapeutic alliance is important factor for assessment/intervention (Sonsterud et al 2019). 53 Impairment in Body Function and Structure Case History/discussion will provide information on physiological and psychological functioning: e.g. language difficulties, temperament etc. Primary Symptom: Discuss sensation of being stuck and/or loss of control and how this impacts functioning. Listen to adult’s description of what their overall experience of stuttering is. 54 Personal Factors: Behavioural Reactions Use of %SS, SSI-4 as described above. Important to assess not only stuttering frequency but also level of struggle, tension etc.  WAASP (self-rated): Five subscales: 1) Behaviours 2) Thoughts 3) Feelings 4) Avoidance 5) Disadvantage 55 Personal Factors: Affective/Cognitive Reactions Overall Assessment of the Speaker’s Experience of Stuttering (Yaruss and Quesal, 2008) WASSP (Wright and Ayer, 2000) Fear of Negative Evaluation FNE scale (Watson and Friend 1969): assessment of anxiety Modified Erickson Scale of Communication Attitudes (S-24) (Andrews and Cutler, 1974): http://web.archive.org/web/20140802072817/http://cehs.unl.edu/fluency/pdfs/eric kson.pdf Locus of Control of Behaviour (Craig, Franklin, Andrews, 1984) 56 Activity Limitations and Participation Restrictions ◦ Overall Assessment of the Speaker’s Experience of Stuttering (Yaruss and Quesal, 2008) ◦ WASSP (Wright and Ayer, 2000) **Informal conversations with client can reveal activity limitations (e.g. talking on phone) and participation restrictions (e.g. reduced socialising). 57 Environmental Factors Assess the adult’s support network, work environment etc. Reactions and attitudes of listeners in environment Listen to their lived experience of stuttering (Connery et a. 2019) Explore benefits of self-help support group attendance e.g. ISA (Irish Stammering Association). Assess for self-stigmatised beliefs 58  Multi-faceted nature of the disorder to be reflected in assessment Assessment must be individually tailored. Wide range of formal assessments available. Summary of Adolescent/Adult Important to use a mix of formal and informal assessments Assessment Important part of assessment is listening to adult’s story Assessment of adult’s overall communication skills is required. Therapeutic alliance facilitates comprehensive assessment. 59 What is your key take home message from today’s lecture? 60 What was the muddiest/ most confusing points in today’s lecture? 61 Resources/References OASES Adult Assessment: Yaruss, S. & Quesal, R.W. (2006) Overall Assessment of the Speaker’s Experience of Stuttering (OASES): Documenting multiple outcomes in stuttering treatment. Journal of Fluency Disorders 31, 90–115. Palin PRS: https://www.whittington.nhs.uk/default.asp?c=28941 Multicultural Stuttering and Treatment: A Cross Cultural Analysis https://opensiuc.lib.siu.edu/cgi/viewcontent.cgi?referer=https://www. google.com/&httpsredir=1&article=1369&context=gs_rp Sonsterud et al. (2019). The working alliance in stuttering treatment: a neglected variable? Int J Lang Comm Disord, 54, 606–619. Stuttering Foundation Podcast: stutteringhelp.org/podcast Stuttering Foundation advice leaflets: https://www.stutteringhelp.org/brochures 62