2: THE ASSESSMENT OF STUTTERING
General guidelines to assessment
The process of assessment
The speech profile
Students should be able to:
Perceive and count overt stuttering symptoms
Carry out and interpret selected attitude assessments
Describe and discuss the controversies about stuttering assessment
Consider the person who stutters as a whole and begin to see how therapy must be designed for the individual
Compare, contrast and critically evaluate the various models of stuttering assessment
Key Text: Chapter 7 Stuttering: an integrated approach to its nature and treatment Guitar
Assessing stuttering is possibly one of the most contentious issues in the whole field of disfluency because the disorder is so variable. As Sheehan (1970) says "it is not a unitary problem". Also the type of assessment which might be done is dependent upon the theoretical standpoint of the clinician. For example those therapists who follow the belief that stuttering is a learned behaviour will assess it from this point of view.
The role of assessment must be strongly related
to outcome measures in the current climate of service provision. Purchasers of
our services have a right to see how effective we have been and think we might
be in future but this always been considered difficult in the area of
stuttering because change is difficult to measure and customer satisfaction is
not always related to a reduction in dysfluency. A good overview can be found
in the paper by DesForges and Rowley
(1994 unpublished but in tied articles)
which discusses this issue for
A further major ethic is that we should not just be assessing the disorder but should be evaluating the person with the disorder. If we do not do this our assessment will bear no relationship to the needs of the individual. However, once we try to do it the number of variables we try to include tend to create confusion. It is still better, however to look at the person as a whole than to simplify the situation but it may help to alleviate the anxiety of the therapist to know that the procedure is complex.
General Guidelines for Assessment
WHO should be assessed
Anyone who is referred or refers themselves, at whatever age. It is vital that children are seen as young as possible i.e. as soon as a parent/ other carer feels any alarm.
WHY assess stuttering (especially if it is so difficult!):
a) differential diagnosis i.e. between stuttering and non stuttering and between subgroups of stuttering
b) obtain base measurements,
c) observe & record change,
d) plan effective therapy,
e) predict outcome of therapy,
f) evaluate treatment and make changes
g) provide outcome measures for purchasers
h) find out more about the nature of stuttering i.e. are there subgroups.
WHEN to assess stuttering
at initial visit
post - treatment
follow-up (this has more often than not been omitted from efficacy of therapy studies)
N.B. because stuttering is so variable even throughout a single day it is hard to find a reliable time
WHERE to assess.
There are major problems in getting representative samples of speech as stuttering often improves in a clinic environment out of all proportion to what it is like outside.
Some authors suggest that there should be covert (secret) assessment but these are suspect on ethical grounds.
WHAT to assess
This refers to both overt and covert characteristics although whether one deals with psychological areas depends on one's theoretical viewpoint. Learning theorists say that people who stutter do not have primary covert problems but only have psychological difficulties resulting from the overt problem. Others feel there is a strong, primary, psychological problem.
There are also different viewpoints as to whether we should assess the ‘moment’ of stuttering (Johnson) or view the total speech behaviour as disordered.
The main ones are repetitions, prolongation and blocks. Others include facial grimacing and body movements, body tension and tremor, vocal fry, repositioning of the articulators, interruptor devices, speaking on complemental air, speaking on inhalation. Reaction to the fear of stuttering include avoidance, postponement, timing devices e.g. several "run - ups" to the word, trigger postures, disguise reactions (laughing it off) and finally a whole history of accessory reactions. Van Riper (1982)
The responses to the experience of stuttering in terms of feelings reactions and attitudes. The basis of all these covert features is fear including fear of loss of self control, fear of listener reaction and fear of revealing the stutter. Causes of fears include situations, conditions of communication, communicative content, linguistic precipitants, phoneme fears and word fears.
Other covert reactions are frustration, hostility and guilt. Any or all of these are at the root of avoidance which is why the perpetuation of avoidance is so harmful. Van Riper (1982)
Bloodstein (1970) said that "If the stutterer were to forget he is a stutterer he would have no further problem." When he does forget, through distraction, fear or anger, for example, he often appears improved.
Sheehan in particular felt that the whole problem is one of attitude. Indeed, a speech technique could produce a kind of avoidance behaviour.
One of the most useful ways of analysing the relative proportion of overt and covert symptoms is to ask the client to draw his or her own "iceberg" (Sheehan 1970) and Byrne (1992) gives a good description in "Lets Talk about Stuttering".
This analogy refers to how the major portion of the problem may lie hidden well below the surface or may be visible above. Sheehan stated that the stutterer needs to convert the concealed behaviour into more open behaviour so that this can be reconditioned.
Individuals differ enormously in the amount/severity of these symptoms and the relative degree of overt/covert qualities. This is obviously of prime importance in planning therapy and most of the assessment procedures are devoted to it as listed below.
Not only do we want to know what someone is doing but also how severe they are and how remediable the problem is.
Assessment of related areas (these tend to be assessed in children rather than adults)
i.e. knowledge of client’s whole world
HOW to assess.
The usual protocol and a selection of some of the methods are as follows:
The Process of Assessment
All therapy must begin with an assessment of the person with the problem. This actually starts with the form of referral e.g. from employer, self referral, from teacher, from parent themselves. All will have different implications for therapy in terms of type of therapy, motivation and outcome.
This should be offered during working hours or school time unless one is specifically working in evenings. If the individual is unable to attend because of the time this must say something about their future commitment to therapy. (Evening classes can always be offered later for therapy). It is very important to stress the level of commitment the professional expects from the client. Some people who stutter do hope for the instant cure and need to adjust to the knowledge that a great deal of time and effort will need to be invested in this change.
The initial appointment can only begin a process of investigation, which should then continue throughout contact. It is important that the therapist is able to adjust style to suit the client involved. Some people have a great deal to say, some stutter too severely and are unable to impart a great deal and young children ought not be conscious of assessment at all.
They start the minute the client enters and include observations of
the way in which a person speaks
the way in which a person stutters
This should give us a very full overview of the person and cannot be completed quickly. All professionals will complete a history whatever their beliefs but they might stress different questions. The information about the past and present of an individual takes time to build so that the professional can see the problem from the point of view of the complainant and the relative importance of each fact examined. In order to do this one needs to take the credulous listening approach (Kelly 1955).This approach is basically one where one accepts what the client says and does not reject those facts (neither silently nor to their faces) which do not fit in with one's own picture. The sort of information one needs to gather and prioritise depends on, for example, he age of the person and their experience of life. It is not until one is better able to subsume the problems of the person in the present that any change for the future can be planned. In the Case History one should try to ask questions that help the client elaborate what they are saying rather than interrogating them. For example it may be useful to follow suggestions made by Hayhow and Levy 1990 , one of which is not to ask the question "Why". but rather "What" and "How" as these "encourage clients to focus on specific behaviours and questions rather than abstract aspects of the problem". Also, always supply what information you can to clarify the picture for them. A useful model to keep in mind is that while you are the expert on the theory of stuttering the client is the expert on themselves.
Authors have devised their own Case History protocols and indeed there are different procedures in different clinic environments. General areas of questioning are as follows:
When dealing with children the history is obtained from the parents paying particular attention to the following:
history of speech complaint
current management of speech problems
other speech /language problems
familial history of stuttering
relationships within the family
When dealing with adults knowledge about the onset and development of stuttering is not as vital unless it is sudden. Other details as they relate to the stuttering problem include:
previous speech therapy and /or other therapy
client's ideas about onset and cause
views on responsibility for stutter
changes in stuttering over the years
best/worst occasions for stutter
expectations of present therapy
model of therapy (doctor/patient, student/teacher, partnership)
type of therapy desired (group or individual, intensive or weekly).
The therapist notes how the information gained by asking these questions relates to their knowledge base about stuttering.
Rustin (1987), in her Assessment and Therapy Programme for Young Children stresses that an in-depth parental interview should take place covering general health, eating sleeping and elimination, muscular system and concentration, speech family structure and history, home circumstances, family life and relationships, child's developmental history and temperamental or personality attributes.
The City Lit suggests Case History questions for adults. They say it is useful to follow a "reasonably uniform approach to our first encounter with a client".
Another way to find out more about the client and their world is to ask them to complete a questionnaire. This can be similar to or different from questions asked in the interview but it allows some clients more time to think and add to information at home.
These tend to be a mixture of both formal and informal methods.
The following section presents the
Speech Profile which assesses the overt symptoms of stuttering and the
Attitude Assessments which are the most frequently used tools by which covert features are assessed.
THE SPEECH PROFILE
The way this is done differs depending on the reasons for doing it. Some reasons are:
· for differentiating incipient stuttering (Riley & Riley 1981/84) (see Onset and Development notes)
· solely for gaining a measure of overt severity
· for deciding upon the type of therapy which should be undertaken (results examined in conjunction with results of covert tests)
The speech profile looks at the overt characteristics of the client and those professionals who feel that stuttering is basically a more psychological problem sometimes do not conduct the frequency count of stuttering in the speech profile. Indeed some therapists feel that a frequency count lacks predictive efficiency and too lengthy an assessment is not useful.
The way to conduct this has been described countless times by different authors. They all have much in common but there are several areas of disagreement. Hayhow 1983 in Approaches to the treatment of stuttering gives a full picture of the points of disagreement outlined below and which are still true today:
1. What to count as stuttering behaviour. How do we know what is a normal non fluency and what is a stutter
2. How to count stutters e.g. is s-s-s-stutter three stutters or one? Stutters differ hugely in their manifestation, the simple distinction being between blocks, repetitions and prolongations. Should we differentiate them or should we group them all together?
3. When working out the percentage of stuttering should we use the syllable or word as the unit of measurement? The syllable tends to be used more often as a) words vary in length, b) the rhythm of speech is built around the syllable, not the word and c) it solves the problem of more than one stutter in a word.
4. We cannot be sure that our result is representative of the person's problem (see where and when).
5. Does frequency really indicate severity (frequent small repetitions vs infrequent massive blocks).
6. How do we decide what is a normal non fluency and what is stuttering?
7. If therapy is not geared towards the elimination of overt factors (as in the case of covert stuttering) then is a frequency count useful?
To reduce unreliability professionals should ensure that their own assessment of individuals is CONSISTENT.
Steps in the Frequency Count Assessment
1. Prepare either a video or audio tape recorder
2. Explain what you will be doing to your client
3 Reading a passage of about 200 words out loud (Rainbow Passage or Arthur the Young Rat). The reason for including reading (in those who can), is that one can then detect the tendency to avoid.
4. Monologue for 2 - 3 minutes using the topics of e.g. job, school or stuttering
5. Dialogue for 2 - 3 minutes on any topic
6. Phone or speak to another person in the clinic who is a stranger to them.
7. Assess the frequency of stuttering in each case using the following
No. of syllables stuttered * 100 = %Syllable stuttered
No of syllables spoken
(N.B. either words or syllables can be used as the unit of measurement but one should be consistent)
What to count as stutters: Repetitions (R)
for the equation Prolongations (P)
(see Onslow below for alternative)
8. In order to assist in conveying the perception of severity, time the duration of the longest stutter.
9. Assess overall speaking rate:
Syllables (SPM) = no. of sylls. spoken in 2 mins
per minute 2
Normal speech rates in syllables range from 162 – 230 spm, with a mean of 196 (Andrews and Ingham 1971) . Normal reading rates are about 210 – 265 spm.
Different authors define different frequency measures and if a therapist is following one of these programmes it is essential that those measures are used. Examples are Onslow (1996/9) and Rustin (1987).
Recently, for example, (Onslow & Packman 1999) suggest that ‘scientists within the field may not be communicating with each other as effectively as they might’ and that ‘the source of this disarray is in the nature of the data language which is inconsistent, illogical, and imprecise and frequently does not portray the behavioural characteristics of the disorder.’
They suggest a data language which will be valid and reliable in describing behavioural features but caution that it is not to be used for differential diagnosis nor as a severity instrument.
Repeated movements Fixed Postures Superfluous Behaviours
Incomplete syllable repetition without audible airflow nonverbal
Multisyllable unit repetition
The frequency count gives a picture of the raw data but this needs to be translated into a picture of severity of stuttering for the individual. The main problem with this, however is that many minor stutters will always appear, on paper, as more severe than the infrequent long contorted stutters which will appear more severe perceptually.
The assessment of frequency and rate together is one of the main methods for assessing severity. There is said to be a correlation between frequency and listener judgements of severity but it is not particularly high (between .41 and .71 Aron 1971).
Other (numerous) semi - formal and formal ways of assessing severity are:
2. Andrew's & Harris 1964. Although this is one of the oldest it remains one of the quickest and most used, offering communication between therapists. It uses a grade system:
Grade 0 - stutter not heard at interview
Grade 1 Mild stutter
0-5% words stuttered
Grade 2 Moderate stutter
Communication slightly impaired
6-20% words stuttered
Grade 3 Severe stutter
Communication definitely impaired
over 20% words stuttered
Their codings for symptoms were:
A: simple repetitions
B: Prolongations and hard blockings
C: Associated facial and body movements.
They also feel that the rate of speech correlates highly with severity and their percentage calculation takes this into account. Below the rate of 140 = or - 24 wpm speech sounds abnormal.
5. Stuttering Severity Instrument - Riley 1972. Yields a single numerical representation of severity within a range of 0 -45 and has three parameters:
a) frequency of repetitions and prolongations
b) estimated duration of longest blocks
c) observable physical concomitants.
A useful tool.
6. Standard Talking Samples - Costello & Ingham 1985. Assessed in terms of frequency, duration, speed, length of stutter-free speech, speech quality and speech behaviour under different "probe" conditions e.g. reduced rate, prolonged speech, rhythmic speech, shadowing, verbal punishment, self-recording, time-out and chorus reading. They use ABAB designs. They do not describe the nature of the moment of stuttering as Costello & Hurst (1981) found that these divisions were not clinically meaningful.
Other factors apart from frequency and rate are usually assessed these days as they are useful for the selection of therapy and give a more complete picture of the whole person.. They include:
1. Consistency of stutters i.e. are they always blocks, repetitions or prolongations? Do they occur at the same valve regardless of the articulation (more severe if so). Is there difficulty starting and a tendency to "runaway blocks" or tension?
2. What is the reaction to stuttering (the person who stutters and listeners)?
3. What are the concomitant or secondary behaviours?
4. What is the fluency like i.e. rate, breathing pattern, accent variation, syllable stress. Does fluency feel easy or "tenuous" and how natural does it sound?
5. What is the average length of non- stuttered intervals?
6. What is the intonation and prosody like?
7. What is the general communicative style like?
Luper & Mulder 1964 provide a checklist for child and adult stutterers and Cooper 1982 in his "Disfluency descriptor digest for clinical use" assesses which of a set of fluency eliciting techniques might be used most advantageously.
Designing a Situation Hierarchy
Because stuttering is so variable it is useful to ask a client to list their situations in order of most to least difficult. Reasons for difficulty can be discussed and the assessment is used when transferring fluency from the clinic to outside. An example might be:
talking on the phone most difficult
talking to a group
talking to strangers
talking to the boss
talking to friends
talking to family least difficult.
Hayhow (1983) notes that there is a controversy about whether or not to assess attitudes. The differences of opinion relate to beliefs about the nature and cause of stuttering and to one's persuasion about the form of therapy that should be given (fluency shaping versus behaviour modification).
Current attitude assessments are unsatisfactory because their reliability and validity are virtually untested and there is always confusion about what the scales measure.
Attitudes are assessed in three main ways:
Specific attitude assessments
Can be for parents, children and adults and ask direct questions about fears, avoidance, situations and relationships etc.
The Situation Questionnaire was developed from Shumak's self ratings for reactions to speech situations and quantifies the amount of avoidance and reaction to these.
These are many, varied and largely, unstandardised. The two commonest are described below:
The S24 Andrews and Cutler 1974 JHSD 39 p315
(Adapted from Erikson's 1969 S39 Scale)
Originally the S39 scale was used to compare stutterers' and nonstutterers' attitudes towards communication but was adapted by Andrews and Cutler in 1974 to select those items which
a) discriminated between the two groups
b) show a strong bias towards normalcy when administered to stutterers improving in treatment and
c) proved reliable when repeatedly administered to stutterers in treatment.
Clients do tend to fill the form in honestly although Preus (1981) said his subjects were inconsistent or failed.
Basically, the higher the score the more disordered the attitude to communication is said to be.
There is a problem relating the results of this assessment to severity in that Andrews and Cutler (1974) and Guitar and Bass (1978) failed to find a correlation. This is probably because those persons skilled at avoidance would have low severity but a high S24. Those with overt symptoms can sometimes have a less "disordered attitude" conversely and there may be different cases for different subgroups. Helps (1975) found that those stutterers who see themselves as like other stutterers have a high S24. Certainly the result is obviously important when choosing therapy i.e.
5% stuttering and more than 9 scored on the S24 equals more concentration on attitudes than on technique and
20% stuttering and less than 9 scored on S24 equals greater concentration on technique than attitude.
Guitar and Bass (1978) say that stutterers who do not show a normalisation of communication attitudes on the S24 by the end of treatment will have a poorer long term prognosis.
Children’s Attitude Test Brutten (1985)
Similar to the S24 and again quite widely researched. Fewer implications noted.
The Perception of Stuttering Woolf (1967)
Asks the person who stutters to evaluate dysfluent behaviour in terms of struggle (20 Y/N statements), avoidance (20) and expectancy (20). It does reflect his attitudes and provide a means of understanding his overt behaviour but it is rather subjective. It cannot be used to determine general communication attitudes or any changes that may occur and it is not useful for reassessment if the individual is using a technique. Here one might expect the expectancy scores to rise.
Locus of Control Craig, Franklin & Andrews 1984
Craig et al developed the scale to measure locus of control of behaviour. What this does is to
assess the extent to which people feel they can influence what happens to them
External - helpless in controlling life
Internal - empowered to influence the course of
In their study to measure the extent to which stuttering subjects perceive responsibility for their personal problem behaviour they found that:
· a reduced internal locus of control is associated with less chance of relapse
· an increased external locus of control is associated with greater chance of relapse
Sheehan's Levels of Avoidance
Through discussion, the therapist discovers at which of the five levels the person is avoiding. The deeper the level the greater is the need for a desensitisation and counselling approach.
The levels are:
ego-protective or "self" level.
Some of the most widely used psychological investigations of attitudes and the meaning of stuttering and change for the individual may be found in the area of Personal Construct Psychology. They include:
The self characterisation
Self evaluation Grid
Happy and Sad faces (children)
Troubles at school
Personal Construct Psychology and therapy and its application to stuttering will be covered in the Developmental Studies Course.
Rowley and DesForges 1994
Look at the different types of outcome measures in disorders of fluency and conclude that “there are a number of approaches ....the key issue is deciding which is the most appropriate. The variability of clients with dysfluency in terms of age and severity alone ensures that it is very difficult to decide upon a single measure which is guaranteed to provide clinicians and managers with what they want - a single reliable, valid, easy to use and understandable measure”. Three areas need to be tapped:
“1. The therapists perception of outcome
2. The client’s perception of outcome
3. The client’s satisfaction”
Some measurement scales in use are appended to their paper
The Wright and Ayre Stuttering Self-rating Profile (WASSP) (Wright & Ayre 2000) is a comprehensive outcome measure for adults for before and following therapy. It examines behaviours, thoughts, feelings about stuttering, avoidance and disadvantage.
The following synopses have been drawn from other texts. Students are advised to go to the Guitar 1998 reference in its entirety
GUITAR AND PETERS 1994 (an earlier edition of the Guitar 1988)
Chapter 6 Assessment & Diagnosis
They set up components of diagnosis: background information
observation of behaviour and feelings
proposal for intervention or not
Keep in mind when seeing new client:
every client is different
consider the person as well as the problem
diagnosis is an ongoing process
For adults and adolescents they have:
pre-assessment information to be collected: a case history form
attitude questionnaires: S24
interview data to be collected:
· the speech sample using Riley’s 1972 Stuttering severity instrument plus speech rate
· comprehension and production of language, articulation and voice and screen hearing
intelligence, academic adjustment, psychological adjustment and vocational adjustment - factors which can affect treatment
Data from parents if dealing with an adolescent
get a picture of how the young client functions within the family and how everyone feels.
The next stage is to determine the developmental/treatment level. This depends largely on age and is determined by how much the client can accept responsibility for self-therapy.
The pre-school child
a case history form is sent out
In the interview:
parent-child interaction is observed
a parent interview is conducted - appears fairly information based and informal
a clinician-child interaction:
talking about stuttering - if the child is unaware then only use non-directive play to
if s/he is aware then how able are they to talk about stuttering
how to deal with a child who won’t talk or who is entirely
Analysis of speech sample:
Pattern of dysfluencies: frequency
nature of repetitions & prolongations
starting and sustaining airflow and phonation
Feelings and attitudes: ask parents if child is:
unaware of dysfluencies
occasionally aware but not really bothered
aware and frustrated by dysfluencies
highly aware, frustrated and afraid
Other speech and language behaviours as in adult section but age appropriate
Other factors e.g.
he next stage is to determine the developmental/treatment level
· normal disfluency
· borderline stuttering
· beginning stuttering
· intermediate stuttering
Information is fed back to the parents at the end of assessment
Elementary school child
Child interview to get:
Feelings & attitudes A-19 scale (Guitar & Grims 1977)
Children’s Attitude Test (Brutten 1985)
Similar stages to other two groups thereafter
Assessment and evaluation
Has three beliefs that influence assessment and evaluation:
1. “Stuttering relates to a complex interaction between the stutterer’s environment and the skill and abilities that stuttering brings to that environment”
2.”Stuttering rarely operates in a vacuum but many times relates to subtle and not so subtle difficulties in other areas”.
3. “Individuals who stutter are individuals first and stutterers second - there is more to their lives than stuttering”.
It is a good chapter on: first impressions as an assessor
the intake form
the interview: structured round styles of questioning:
a) direct - open
b) open ended questions
c) leading questions - loaded
requiring a yes/no response
d) non-directive questioning a) mirroring
b) verbal probes
standardised and nonstandardised assessment and evaluation of
communicative and related skills
written documentation of findings
His data is summarised in a single sheet copied at the end.
WALL & MYERS 1995
Their chapter concentrates on differentiating NNF from stuttering and also considers stuttering assessment from the three-factor model they propose. They use a matrix of stuttering behaviours to detail what is actually occurring in speech and have diagnostic questions within each factor but stresses that a gestalt approach to assessment is paramount.
1. Does the child know he or she sometimes has fluency disruptions?
2. If the child knows, how does he or she react?
3. How does the fluency behaviour affect the parents and other family members?
4. How do the parents’ communication behaviours influence the child?
5. What situations appear to provoke or to ameliorate the fluency breakdowns?
6. How is the child’s adjustment to his/her speech and to the reactions of others?
Physiological questions involve:
3. Coarticulatory and aerodynamic factors
4. Summary remarks
Associated or secondary characteristics are also important as are situational factors.
They advocate the use of other scales and protocols.
Andrews and Cutler The Relationship between changes in symptom level and attitude JHSD 39 312 - 319 1974
Andrews and Ingham Stuttering: Considerations in the evaluation of treatment BJDC 6 129 - 138 1971
Bernstein Ratner N Language and Stuttering (in press) (kept in tied articles)
Conture Stuttering (1995)
Cooper A disfluency Descriptor Digest for Clinical Use JSHR 7 1982
Costello and Hurst An analysis of the relationship among stuttering behaviours JSHR 24 247 - 256 1981
Craig, Franklin & Andrews 1984
A scale to measure locus of control of behaviour B J of Medical Psychology 57 173-180
DesForges & Howell An overview of outcome measures (1994) (tied articles)
Guitar Pre-treatment factors associated with the outcome of therapy JSHR 19 590 - 600 1976
Guitar Stuttering: an integrated approach to its nature and treatment 1998 Chapter 7
Onslow (1996) Behavioural management of Stuttering
Peters & Guitar Stuttering: an integrated approach to its nature and treatment (1991)
Riley A stuttering Severity Instrument for children and adults. JSHD 37 314 - 322 1972
Rotter 1966 - Generalised expectancies for internal vs external control of reinforcements Psychological Monographs 80,1-20
Rustin Assessment and Therapy Programme for Young Children 1987
Wall & Myers Clinical Management of Childhood stuttering (1995)
Woolf The assessment of stuttering as struggle, avoidance and expectancy BJDC 2 158 - 167 1967
Wright L & Ayre A Wright and Ayre Stuttering Self-rating Profile (WASSP) (2000) Winslow Press