Fluency Evaluation
July 7, 2013
Client:
Date of Birth:
Address:
Phone:
Parents:
Referral Source(s):
School:
Graduate Clinicians:
Clinical Faculty:
Diagnosis and Code:
XX
June 5, 2009
C.A. 4 years, 1 month
XX Street
Burlington, VT XXXXX
(XXX) XXX-XXXX
XX & XX
XX
XX
XXX, B.A. & XXX, B.S.
XXX, M.S., CCC-SLP
Childhood onset fluency disorder (315.35)
Referral Questions:
How can X’s stuttering be remediated?
What treatment program is most appropriate for X?
Background:
X is a 4 year, 1 month old boy who lives at home with his parents, X and X, and his two
brothers, T and B. He was accompanied to today’s evaluation by his mother, M. X’s birth history
is remarkable for an emergency delivery via Cesarean section at 41 weeks gestation. However,
his subsequent development was reported to be typical and his medical history is otherwise
unremarkable. X writes with his left hand and kicks a ball with his right foot. There is no family
history of stuttering or other speech/language disorders.
X’s stuttering was first noticed by the family in December of 2012, when he was about three
years old. After monitoring his stuttering for a year, X’s speech was then evaluated by his
preschool speech language pathologist, XXX, M.S., CCC-SLP in January of 2013 for continued
concerns about articulation and fluency. At that time, he received a standard score of 105 on the
Goldman Fristoe Test of Articulation – 2nd edition (GFTA-2), indicating his articulation was age
appropriate. His stuttering was scored as “moderate” on the Stuttering Severity Instrument – 4th
edition (SSI-4), with an average of 7% syllables stuttered.
X then received 11 weeks of speech treatment with XX, M.S., CCC-SLP at school, but then “he
seemed to get stuck” and no further improvement was observed based on his mother’s report.
Treatment was discontinued after he plateaued at an average severity rating of 4 (on a 1-10 scale
in which 1= no stuttering and 10= the most severe stuttering imaginable). Today’s assessment
was conducted to determine if X would benefit from formal treatment at the Eleanor M. Luse
Center to address his continued fluency difficulties.
XX: Page 1 of 7
Assessment Findings (Non-standardized):
Parent Interview:
When asked about the onset of X’s stuttering around age three and a half, M reported that it
began as “a little problem,” but worsened when his younger brother B was born, and again after
switching to a new school. M expressed her hope that X’s stuttering could be addressed before
he starts kindergarten next year.
When asked about X’s personality, M described him as “night and day” depending on the
setting. At school, she described him as typically shy, speaking very little and waiting for other
children to invite him to play instead of joining groups on his own. M reported that X has
vocalized that he feels like he has no friends. Conversely, at home X is typically “loud” and at
times boisterous, and he interacts well with both his brothers and cousins.
M described X as a “sensory kid.” He is sensitive to touch (e.g., tags on his shirts), sounds (e.g.,
the kitchen mixer, sirens), and in the last month has been chewing and licking whatever is
accessible to him, including his clothing and toys. M has not noticed a consistent pattern,
explaining that it happens at “random times” and does not seem to be anxiety-related. X likes
order and is often observed lining up his shoes at home or making sure the left and right shoes
are together in a pair. He exhibits similar behavior with his toys, and this was observed at the
beginning of today’s evaluation when X lined up his toy cars. M reported that her brother, a
special educator, had suggested that these behaviors could be X’s way of exerting control in a
world where he feels that many things are beyond his control.
M reported that X has “good days and bad days,” stating that his stuttering seems to increase
when he is tired, excited or nervous. However, she shared that “he has never had a day where he
hasn’t stuttered.” She described his stuttering as mainly partial and whole word repetitions at the
beginning of a sentence or after a pause. She reported that “th” sounds tend to present particular
difficulty for X, but he does not seem to avoid specific sounds or words and generally “keeps
stuttering until he gets out.”
However, M mentioned she has noticed X occasionally changing his word choice once he “gets
stuck” on a word. M used Severity Ratings on a scale of 1-10, in which a score of 1 indicated no
stuttering being present (with the exception of normal disfluency), a 2 indicated very mild
stuttering, and a 10 indicated the most severe stuttering she could imagine for X, to rate his
stuttering in a variety of contexts. She rated him a 4 or 5 during the evaluation and a 5 at home,
stating that his stuttering is more severe at night. She shared that the lowest rating he has ever
been is a 2 or 3 and the highest he has ever been is a 7.
When asked about how X reacts to his stutter, M shared that he does not seem to notice it. She
also revealed that the majority of his family does not react to his stutter and they just “let him
go,” but his older brother, T, is starting to notice it and react to it by repeating X’s stutter. She
expressed concern in regard to not knowing how to best handle this situation, and it was
suggested that she be open and straightforward with T about why it is important to not tease X
about his stutter. An open dialogue will provide T with information about ways he can help, for
example waiting and letting X finish what he wants to say.
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Parent-Child Interaction:
X’s mother, M, engaged in a play-based interaction with X at the beginning of the evaluation.
During this interaction, X was talkative and absorbed in both the play and his conversation with
his mother. M allowed him to direct their play while commenting on what he was doing and
what he was discussing. While M was talking, she was calm and spoke at a slow rate. Few
questions were asked of X that would put demand on him to speak. M included frequent pauses
and often repeated what X said back to him, giving him the floor to speak without making him
feel pressured. M’s interaction style encouraged more speech from X. She engaged in his play,
often leaning in and participating without being directive.
The vocabulary M used was appropriate for X’s developmental level and was not too complex.
During instances in which X displayed stuttering behaviors, M acted naturally and continued on
with the flow of the interaction. Overall, M’s interaction style relieved any pressure or demand
placed on X to talk. The low stress, laid-back environment M created was highly supportive of
his fluency.
Clinician-Child Interaction:
Following the parent-child interaction, X engaged in a one-on-one play session with one of the
clinicians. Although he was shy at first, he soon warmed up and talked about the movie Cars, his
Batmobile toy, and his favorite games to play on the Nintendo Wii. The clinician commented on
what X was doing during play in addition to things he was saying and introduced topics of
interest to keep the conversation going. X was observed to stutter more in conversation with the
clinician than he did interacting with his mother. This could be due to X’s shyness and the
pressure of having to talk to someone he did not know.
He made little eye contact during the interaction, which may be due to his preoccupation with the
connector toys he was using to build bridges and jumps. He did not show tension or struggle
when he became stuck on a word, and no physical concomitants were observed (e.g., head
movements or eye blinks). He did not appear to be bothered by his stuttering, and in most cases
was able to get the word out after a few repetitions. At other times he changed the word he was
trying to say, occasionally stuttering on the initial sound of multiple different words before being
able to move forward. (e.g., “Yeah, y-y-y-y-, i-i-i-i-, d-d-d-, car-car-car-cars two”).
Assessment Findings (Standardized):
State-Trait Anxiety Inventory for Adults (STAI):
The STAI is a standardized assessment tool that measures anxiety levels in adults. It
differentiates between an individual’s temporary “state anxiety,” which is dependent upon the
situation, and their “trait anxiety,” which is constant regardless of situation. Raw scores range
from 20-80, with higher scores corresponding to higher levels of anxiety. This measure is used in
a child fluency evaluation to gain a better overall picture of the child’s environment.
STAI
Mother
State
Trait
Raw score
Standard
Score
Percentile
Rank
25
40
13
Raw score
Standard
Score
Percentile
Rank
29
42
25
Note: Percentile ranks between 16-84 indicate normal range with 50th percentile representing the mean
XX: Page 3 of 7
X’s mother scored below the normal range (16-84th percentile) on the state anxiety scale and
within the normal range on the trait anxiety scale on the STAI, which indicates that both her
temporary “state” and constant “trait” anxiety are low compared to adults her age. This suggests
that she is not generally an anxious person, which is a positive characteristic for X’s
environment.
Intelligibility Rating:
X’s articulation was not formally assessed today, as it had been evaluated in March of 2011 by
his school speech-language pathologist R and was found to be within normal limits for his age at
that time. Therefore, X’s articulation was not a primary focus of today’s evaluation. The
articulation errors observed during conversation today were on later-developing sounds, such as
“th.” For example, X often said “dem” instead of “them,” substituting the “d” sound for “th.”
According to normative data, children are expected to be 100% intelligible by four years of age,
meaning that unfamiliar listeners should be able to understand what the child is trying to
communicate, even if their articulation is imprecise. It was noted that the combination of X’s
articulation errors and disfluencies, during which he stuttered on consecutive or multiple words,
reduced his overall intelligibility to about 75%, as judged subjectively by the clinicians.
Speech Rate:
An individual’s speech rate can correlate with their fluency and the severity of their stuttering. In
many individuals, speech rate may be increased or reduced, which may affect their fluency
and/or overall intelligibility (i.e., how they are understood by other communication partners). A
rapid speech rate may affect one’s communication, specifically their ability to maintain a fluent
manner of speaking and be understood.
X’s speech rate was assessed during a conversation with the clinician. The results analyzed from
this speaking sample are given in the table below:
Sample
Speaking Sample
Speech Rate (syllables per minute)
165 spm
Guitar, B. (2006). Stuttering: An integrated approach to its nature and treatment. Baltimore, MD: Lippincott Williams & Wilkins.
Research suggests that speaking rates for children who are five years old range from 109-183
syllables per minute. Therefore, X’s speaking rate of 165 syllables per minute falls within the
average range when compared to peers of the same age.
Speech Sample Analysis:
The Stuttering Severity Instrument-4 (SSI-4):
The SSI-4 is a standardized assessment tool that that analyzes an individual’s disfluencies in their
speech. It analyzes the frequency of stuttering, referred to as the percent of syllables stuttered
(%SS), duration or average time of the three longest stuttered events, and physical concomitants
which are secondary behaviors that coexist with the stuttered events (e.g., facial tension, reduced
eye contact, etc.). The combination of this data results in an SSI-4 severity rating. Two speech
samples from the day of the evaluation were analyzed using the SSI-4. The results are
summarized on the following page.
!
XX: Page 4 of 7
Section of the SSI-4
Frequency (%SS)
Conversational Speech Sample with Parent
(467 syllables)
Frequency (%SS)
Conversational Speech with Clinician
(387 syllables)
Duration (average of 3 longest stuttering events)
Physical Concomitants
Findings/Observations
Task Score
7.2%SS
14
11.8%SS
1.8 seconds
Minor lack of eye
contact
Total Overall Score
Percentile
SSI-4 Severity Rating
6
1
21
41-60
“Moderate”
Subjective Observations:
X’s speech was characterized by repetitions of initial sounds (e.g., “th-th-that”), and syllables
(e.g., “bat-bat-batmobile”). He occasionally had prolongations of vowel sounds (e.g.,
“uuuusing”). No overt physical concomitants were observed, and although he made minimal eye
contact with the clinicians, this did not appear to be directly related to instances of stuttering.
When he became stuck on a word, X occasionally changed what he intended to say instead of
completing the original word. This type of avoidance is not accounted for in the SSI-4 scoring,
which quantifies only physical manifestations of avoidance. By changing words, X also
demonstrated some negative awareness of his stuttering.
Summary & Interpretation:
X is a four year-old boy who presents with a “moderate” overall stuttering severity rating based
on the SSI-4, the standardized measure of stuttering used today. Also included in the diagnostic
evaluation were: an analysis of the parent-child interaction style, clinician-child interaction, inclinic parent interview, analysis of speech rate, informal intelligibility rating and parent anxiety
questionnaire (STAI).
X’s stutters were characterized by initial sound and initial syllable repetitions (e.g., w-w-well,
bat-bat-batmobile). Notably, his longest stutters occurred at the beginning of the interaction and
reduced in duration as the conversation progressed. X produced more stutters (11.8%) when
speaking with the clinician versus speaking with his parents (7.2%). This may be due to X
feeling more comfortable and relaxed with his parent, which promoted more natural,
conversational speech than with the clinician.
Findings from the parent-child interaction reveal that X’s mother, M, already employs a variety
of communicative strategies that facilitate fluency. Her interaction style included frequent
comments on what X was doing and a child-directed style of play. Few questions were asked of
X, and M allowed for pauses to occur between communicative exchanges. All of these
tendencies function to take the pressure to speak off of X.
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The parent anxiety questionnaire (STAI), revealed that X’s mother exhibits low levels of anxiety
compared to adults her age. While research is clear that parents do not cause stuttering, M’s low
level of anxiety reflects another fluency-enhancing component of X’s home environment.
In the clinician-child interaction, X was shy at first, but he warmed up when the conversation
turned to topics of interest. The overall frequency of his stuttering increased compared to his
interaction with his mother, although he did not seem bothered by it and showed no tension or
struggle. X demonstrated awareness of his speech by occasionally changing the word he was
trying to say when he got stuck in a stutter. Although avoiding stutters indicates a negative
awareness of his speech, the ability to self-monitor is an important skill that can be helpful in
treatment when used in a positive way. X’s developing self-awareness is a good prognostic
indicator for future treatment.
X’s speech rate was calculated to be 165 syllables per minute, which places him within the
normative range compared to age-matched peers. This suggests that his speech rate is not likely
to be affecting his fluency to the point that he is unable to effectively communicate verbally.
Additionally, X’s intelligibility was estimated to be about 75% as judged subjectively by
clinicians. This rating was affected by a combination of his articulation errors and disfluencies,
specifically involving his tendency to stutter on multiple words in a row, as well as his quiet
voice.
Recommendations:
Based on the results of today’s assessment, the following recommendations were discussed with
X’s mother:
•
Lidcombe Program Treatment: It is recommended that X participate in fluency
intervention at the E.M. Luse Center as soon as an opening becomes available.
Treatment will be bi-weekly (50 minutes per session) and will involve the Lidcombe
Program of early stuttering intervention. The Lidcombe Program is a parent-directed
treatment which includes specific verbal feedback for stutter-free and stuttered speech
during natural speaking conversations. The family will be contacted as soon as an
opening for treatment becomes available (ideally in February 2012).
•
Severity Ratings: X’s mother was provided with forms and information regarding
the collection of Severity Ratings (SRs) to track X’s daily fluency prior to starting
treatment. SRs are recorded based on an overall daily average score from 1-10 (1 = no
stuttering or normal disfluency, 2 = very mild stuttering, 10 = the most severe
stuttering imaginable for any child). These ratings will be valuable when X begins
therapy at the clinic to identify patterns in his stuttering behavior. These ratings
should be emailed to XX once per month to the supervising clinician at:
[email protected].
•
One-on-one Interaction Strategies: Additionally, it is recommended that X’s
parents set aside some time each day to interact one-on-one with X, focusing on using
the positive interaction strategies discussed during the evaluation and outlined in the
XX: Page 6 of 7
report. It is important that X is not praised for “smooth talking” during these
interactions in order to ensure efficacy of the Lidcombe Program in treatment once it
is formally initiated at the clinic.
•
Family Strategies: X’s mother expressed concern related to X’s brother, T,
beginning to notice and point out X’s stuttering and uncertainty in how to address this
situation. Openness is suggested in speaking with T about this, pulling him aside to
explain that it will help X if the whole family acts natural and listens patiently until X
is finished without interrupting or walking away.
Prognosis:
If the recommendations are followed, X’s prognosis is excellent based on family commitment
and support, his age and developing awareness of his speech, as well as early success in previous
treatment.
It was a pleasure working with X and his mother today. If there are any questions or concerns
regarding this report or the information contained within it, please contact the E.M. Luse Center
at (802) 656-3861.
________________________
YY, B.A.
Graduate Student Clinician
_________________________
XXX, M.S., CCC-SLP
Speech-Language Pathologist
Clinical Educator
Cc: XX & XX
X Street
Burlington, VT 05401
XX: Page 7 of 7
__________________________
ZZ, B.S.
Graduate Student Clinician