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 C H A P T E R

Assessment of
FLUENCY 13
DISORDERS KEY WORDS
Accessory behaviors, Avoidance
behaviors, Between-word
disfluencies, Blocks, Broken
Naomi Eichorn, M.S., CCC/SLP, TSSLD Renee Fabus, Ph.D., CCC-SLP, TSHH
words, Clusters, Cluttering,
Adjunct Lecturer Assistant Professor
Core behaviors, Disfluency,
Department of Speech, Language Department of Speech Communication Arts
and Hearing Sciences and Sciences Dysfluency, Escape behaviors,
Lehman College of he City University of New York Brooklyn College of the City University of New York Incipient stuttering, Interjections,
Speech-Language Pathologist Locus of control of behavior
Adler, Molly, Gurland, LLC (LCB), Prolongations, Real-time
analysis, Repetition, Revisions,
Running starts, Spontaneous
recovery, Stutter-like disfluencies
(SLDs), Tremors, Within-word
disfluencies

347
348 CHAPTER 13

differential diagnosis of stuttering and cluttering. For

INTRODUCTION more information on any of these topics, please see the
Among the diverse speech and language disorders suggested reading list and websites provided at the end
we work with as clinicians, fluency disorders seem to of this chapter.
maintain a sense of ambiguity and challenge. We have
certainly made great strides in understanding various DEFINING STUTTERING
potential causes of stuttering; nevertheless, a definitive
notion of its etiology continues to elude researchers. By Most laypeople describe stuttering as chronic inter-
its very nature, stuttering is a condition of inherent con- ruptions in the rhythm, flow, or fluency of speech.
trasts. It involves surface features that are easily acces- Researchers too, have traditionally defined stuttering
sible for measurement and analysis, but is almost always based on these general parameters (e.g., Andrews et al.,
complicated by a vast underlying set of emotions that 1983; Cordes, 2000; Sommer, Koch, Paulus, Weiller, &
are more difficult to label and organize but that are crit- Buchel, 2002). What complicates this understanding is
ical to our assessment and treatment. Sheehan (1970, that many of the behaviors observed in the speech of
p. 14) aptly described overt characteristics of stuttering stutterers are, to some extent, observed in all speakers
as “the tip of the iceberg,” an analogy that highlights the (Ambrose & Yairi, 1999; Wingate, 1964; Yairi, 1997).
need for clinical protocols that take into account both Ultimately, much of what we call “stuttering” is based
symptoms that are perceptible as well as those that may on listener perceptions of what constitutes “typical” or
be more challenging to observe, but that play a critical “atypical” types of interruptions in the flow of speech as
role in driving the development of this disorder. well as listener-defined norms for the frequency with
Our aim in this chapter is to present clinicians with which these can occur before they become exceedingly
an accessible assessment guide that, in the tradition of distracting. As stated by Bloodstein (1995, p. 10), stut-
Sheehan’s metaphor, considers both surface and under- tering may be defined as “whatever is perceived as stut-
lying symptoms associated with stuttering. It is our hope tering by a reliable observer who has relatively good
that clinicians reading this chapter will feel empowered agreement with others.”
to help clients and parents through the diagnostic pro- Despite an ongoing lack of consensus, certain
cess more effectively and be able to mitigate the con- aspects of stuttering have been identified as critical to
fusion and frustration often complicating this journey. its definition and diagnosis. In one description of stut-
Like many other challenging experiences, the process tering provided by the American Speech-Language-
of understanding and to treat stuttering, often spurs a Hearing Association’s (ASHA) Special Interest
deep and ultimately rewarding form of self-exploration Division for Fluency (ASHA, 1999), emphasis is
in which individuals who stutter discover, examine, placed on the specific types of disfluency that are pres-
and learn to change certain attitudes and psychological ent: “Stuttering refers to speech events that contain
tendencies. It is a unique experience to be a catalyst for, monosyllabic whole-word repetitions, part-word rep-
and to be a part of this process. etitions, audible sound prolongations, or silent fixations
In the sections that follow, we provide an overview or blockages. These may or may not be accompanied by
of stuttering disorders and describe a number of key accessory (secondary) behaviors (e.g., behaviors used to
parameters considered during the assessment process. escape and/or avoid these speech events).” According
We then review the specific components of an evalua- to Starkweather and Givens-Ackerman (1997), stut-
tion for three age groups: preschool children, school-age tering refers to discontinuities in speech that are not
children, and adults. Our discussion will focus primarily only excessive in frequency and duration, but also add
on stuttering disorders, rather than related fluency dis- an unusual amount of physical and mental effort to the
orders such as cluttering, neurogenic stuttering, or psy- act of speech production. In his classic definition, Van
chogenic stuttering, although we do briefly consider the Riper (1982) suggested that stuttering “called attention
 A S S E S S M E NT OF F L U E NC Y D IS OR D E R S 349

to itself ” and distracted listeners from the intended not fluent. The prefix dys- has a more clearly negative
message. Certain researchers (Perkins, Kent, & Curlee, connotation and refers to something atypical, difficult,
1991) have emphasized the need to look beyond all or bad. Dysfluency, thus, implies that the lack of fluency
objective speech and nonspeech behaviors and define is deemed abnormal. In general, it is preferable to use
stuttering as disruptions of speech in which the speaker the term disfluency because this term encompasses both
experiences a loss of control. This chapter attempts to inte- speech interruptions that are normal as well as those that
grate the various notions of stuttering described in the may be abnormal. Referring to speech behaviors as “nor-
literature and will be based upon the understanding that mal dysfluency” is obviously incorrect, as this phrase rep-
stuttering involves not only a characteristic set of mea- resents an inherent contradiction of terms (see Guitar,
surable behaviors but also certain subjective experiences 2006, p. 5, and Quesal, 1988, for further detail on this
and perceptions that take on increasingly greater signif- topic). In this chapter, we will use the word disfluency to
icance as a child grows and his or her stuttering evolves. refer to all discontinuities in speech production, whether
This perspective is reflected in the International typical or atypical. Disfluencies that clearly represent a
Classification of Functioning, Disability, and Health devel- fluency disorder will be referred to as stuttering.
oped by the World Health Organization (WHO, 2001),
which recognizes that complex disorders, such as stutter- ONSET AND PREVALENCE
ing, involve not only physical impairment in structure or
function, but also limitations on an individual’s activities
OF STUTTERING
and restrictions on his or her participation in life. This more Although a great deal of vagueness persists in how we
holistic approach encourages us to look beyond superficial define stuttering, there is much that we do know about
behaviors observed in people who stutter and consider the disorder and has been confirmed consistently over
the broader health experience and real-life, everyday chal- years of research. First, large numbers of typically devel-
lenges associated with this disorder. This concept has been oping young children demonstrate normal speech dis-
used as the basis for a number of assessment profiles and fluencies between the ages of 2 and 5 years (Ambrose &
scales, and is discussed further in our review of specific Yairi, 1999), when they are experiencing rapid growth
assessment measures later in this chapter. in the areas of speech and language. Early signs of stut-
Shapiro (1999, pp. 9–12) identifies three broad cat- tering, or incipient stuttering, are most likely to occur
egories of stuttering definitions: (1) descriptive defini- during this same period, when children are beginning
tions, which focus on visible and/or audible stuttering to combine three or more words together (Bloodstein, 13
behaviors; (2) explanatory definitions, which emphasize 2006), and are differentiated from normal disfluencies

FLUENCY DISORDERS
feelings and attitudes in the person who stutters; and based on specific speech characteristics that will be
(3) combined descriptive and explanatory definitions, described in more detail in the following sections. The
which include both aspects of the disorder. The sections prevalence of stuttering is also highest among preschool
that follow describe an approach to the assessment of children compared to school-age children and adults,
stuttering disorders that represents a combined descrip- with estimated prevalence rates of approximately 2.4%,
tive and explanatory perspective to stuttering; that is, we 1%, and less than 1% for the three age groups, respec-
present methods for measuring and understanding both tively (Andrews et al., 1983; Beitchman, Nair, Clegg, &
overt and covert symptoms that may be present. Patel, 1986; Bloodstein & Bernstein Ratner, 2008, p. 79).
In defining stuttering, it is also useful to differenti- These age-based variations reveal another important
ate between the terms disfluency and dysfluency. While fact about stuttering that becomes critical in the diag-
the words are sometimes used interchangeably (often nostic process, which is that numerous preschool chil-
incorrectly), they are distinct in meaning. The prefix dis- dren who stutter experience “natural” or spontaneous
implies a lack of something or the opposite of some- recovery without any formal intervention or treat-
thing; disfluency, thus, refers to speech that is simply ment. A prospective study by Kloth and colleagues
350 CHAPTER 13

(Kloth, Kraaimaat, Janssen, & Brutten, 1999), for Core Behaviors

example, found that stuttering symptoms subsided in
70% of young stuttering children followed over a 6-year The key feature of stuttering is the presence of invol-
period. Numerous researchers (e.g., Ramig, 1993) have untary discontinuities in the flow of speech. These are
suggested that recovery rates may be somewhat more traditionally called core behaviors (Van Riper, 1982)
modest; however, it is well accepted that a young child and consist of three basic symptoms: repetitions, pro-
who stutters is by no means destined to a lifetime of longations, and blocks.
stuttering. This situation has made it imperative for Of all the core behaviors, repetition is the most
researchers and clinicians to identify factors related to common form of disfluency observed in both typically
the child or to the child’s stuttering that might predict developing children as well as children who are dem-
its chronicity or its likelihood to be outgrown. onstrating early stuttering (Ambrose & Yairi, 1999;
Of all the child-related and speech-related vari- Bloodstein & Bernstein Ratner, 2008, p. 31). Repetitions
ables examined in the literature, the factor most reliably may occur at the phrase, single-word (single-syllable
associated with recovery is the child’s gender, with girls word and multi-syllabic words), syllable, or sound level.
being far more likely to outgrow early stuttering and The size of the speech unit affected plays an important
boys being more likely to persist. Male-to-female ratios role in classifying the disfluency as typical or atypical.
appear to be approximately equal at or near the onset In general, the smaller the unit being repeated, the more
of stuttering (Kloth et  al., 1999) but steadily increase likely it is that the behavior represents stuttering. This
as children get older, with ratios ranging from 3:1 to concept is considered further in our later discussion on
stutter-like disfluencies (SLDs).
5:1 during school years, and higher ratios in adulthood
Prolongations are disfluencies in which sound or
(Andrews et al., 1983; Bloodstein & Bernstein-Ratner,
2008, p. 79; Curlee, 1999). This pattern is consistent airflow continues but movement of the articulators
with gender differences reported for a variety of other is stopped, and can occur on continuant consonants
neurodevelopmental disorders (e.g., Baron-Cohen, (s, f, th, sh, v, z, w, r, l, y) or vowels. Prolongations are
2008; Halpern, 1997; Shaywitz et al., 1995). Research generally judged by listeners to be an atypical form of
in the area of early stuttering has identified numerous disfluency (Cordes, 2000) and are most often observed
additional factors associated with greater likelihood later than repetitions, although they are sometimes
for recovery; these are reviewed later in our section on reported at the onset of stuttering as well (Yairi, 1997).
Blocks involve stopping of both airflow and sound
assessment of stuttering in preschool children.
during the production of speech. Blocks are usually the
last core symptom to be observed in the development
CHARACTERISTICS of stuttering and are almost always perceived by listen-
OF STUTTERING: ers as an abnormal type of disfluency. Some researchers
(e.g., Schwartz, 1974) have suggested that blocking is
GENERAL SYMPTOMS caused by inappropriate tensing of muscles at the level of
Reported rates of spontaneous recovery vary widely in the glottis; however, others believe this obstruction may
the literature, but it is clear that a considerable number occur at the respiratory, laryngeal, and/or articulatory
of young children with disfluencies will develop chronic levels of speech production (e.g., Guitar, 2006, p. 15).
stuttering. This section will provide an overview of gen- Two additional behaviors may be observed in indi-
eral symptoms and characteristics of stuttering disorders viduals who stutter. Both tend to be somewhat less com-
and outline details to help clinicians differentiate between mon and are generally perceived as atypical (Cordes,
typical and atypical forms of disfluency. Three critical 2000). Broken words are blockages in the middle of a
groups of symptoms will be reviewed: core behaviors of vowel, during which there is audible laryngeal tension,
stuttering, accessory behaviors, and emotional reactions. followed by abrupt reinitiation of the vowel. Tremors,
 A S S E S S M E NT OF F L U E NC Y D IS OR D E R S 351

often observed in individuals with advanced forms of been made by both researchers and clinicians to dis-
stuttering, involve rapid fasciculations (small involun- tinguish between those behaviors that are more likely
tary contractions or twitching) of the speech muscles. or less likely to represent symptoms of stuttering. One
A final group of disfluencies includes behaviors that are classification system reviewed by Zebrowski and Kelly
less likely to be considered atypical based on listener per- (2002) divides disfluencies into two broad categories:
ceptions (Cordes, 2000; Zebrowski & Conture, 1989), but (1) between-word disfluencies, which include all diffi-
that may occur with excessive frequency in the speech out- culties that occur while a speaker is attempting to link
put of people who stutter. These behaviors are sometimes words together (phrase repetitions, interjections, run-
categorized as forms of avoidance (discussed in more detail ning starts, revisions); and (2) within-word disfluencies,
later in the chapter) rather than core behaviors because which include all discontinuities that interfere with
they may represent attempts on the part of the speaker the smooth transitioning between sounds or syllables
to gain control of his or her speech or avoid an antici- within a word (sound repetitions, syllable repetitions,
pated block. These disfluencies include: (1) interjections prolongations, blocks, broken words).
(often called “fillers”), in which speakers insert extrane- Within-word disfluencies are sometimes called
ous, meaningless words or phrases such as “um,” “you stutter-like disfluencies (SLDs) (Yairi, 1997) and are gen-
know,” or “like” into the flow of connected speech; erally understood to be more associated with chronic
(2) running starts, in which speakers return once or sev- forms of stuttering. Accurate classification of whole-
eral times to the beginning of a thought or sentence in word repetitions is somewhat ambiguous (e.g., see
an attempt to regain fluency; and (3) revisions, in which Wingate, 2001); however, most researchers categorize
phrases or whole sentences are reformulated, often to repetition of single-syllable words as within-word dis-
avoid anticipated difficulties on specific words or sounds. fluencies or SLDs and repetition of multi-syllabic words
Because many of the disfluencies just described are as a form of between-word disfluency (e.g., Wingate,
observed in normal speakers, a great deal of effort has 1964). Table  13-1 summarizes the various forms of

Table 13-1. Types of Disfluency.

Between vs. Within- Stutter-Like

CORE BEHAVIOR Example Word Disfluency Disfluency
Phrase repetition “I want-I want to go now” Between No 13
Word repetition (multi-syllabic) “Cinnamon-cinnamon-cinnamon and sugar” Between No

FLUENCY DISORDERS
Word repetition (single syllable) “He-he-he wants some water” Within Yes
Syllable repetition “The par-par-party is at 6:00” Within Yes
Sound repetition “My name is D-D-D-David” Within Yes
Sound prolongation “I fffffeel good” Within Yes
Block “Do you (tense pause, often with fixed articulatory Within Yes
posture for subsequent sound) want some?”
Broken word “Gi-(silent pause)-ive it to me” Within Yes
Interjections “I, um, like to travel” Between No
Running Start “She wants to go with us to the-she wants to go with us Between No
to the fair”
Revision “I really like to-I really love ice cream” Between No
© Cengage Learning 2012
352 CHAPTER 13

disfluency and provides examples of each behavior and Table 13-2. Categories of Accessory Behaviors.
their classification based on the two systems presented. Escape Avoidance
Behaviors Behaviors
Accessory Behaviors Purpose Terminate block Circumvent anticipated
disfluencies
As disfluencies persist, the person who stutters begins
Examples Blinking, moving Word substitutions,
to develop an awareness of his or her difficulties. It is
head, stamping feet stalling, using starters
at this point that the disorder starts to become more Source: Based on Guitar (2006).
complex and often more severe, as layers of percep-
tions, expectations, feelings, and attitudes begin to Emotional Reaction
take root beneath the surface symptoms. The emer-
gence of accessory behaviors is often one of the Ongoing struggle in the production of speech gradu-
first signs that a child’s stuttering is probably not ally results in deep-rooted feelings of shame, frustration,
developmentally typical (Zebrowski & Kelly, 2002, anger, anxiety, fear, negative self-perceptions, and, even-
pp. 15–16) and that it has progressed from its earli- tually, habitual avoidance of speaking situations. Young
est form. These behaviors, sometimes referred to as children may already manifest strong emotional reac-
secondary behaviors, secondary stuttering characteristics, tions to their stuttering by 5 years of age, or even earlier
secondary mannerisms, extraneous behaviors, or concom- (see Bloodstein, 1995, p. 49). Some children may stop
itant behaviors, represent the reaction of the person talking for several days or develop a habit of asking par-
who stutters to his or her speech difficulties and usu- ents to speak for them. Older children may avoid oral
ally begin as a random struggle, through which the presentations or voluntary participation in class. Adults
speaker tries to push out of involuntary repetitions, may avoid the telephone and begin withdrawing from
prolongations, and blocks. social situations. Starkweather and Givens-Ackerman
Over time and with repetition, these behaviors are (1997, p. 34) describe a startling form of avoidance in
reinforced and become learned patterns that accom- which individuals who stutter may “lose touch” with
pany core disfluencies. These behaviors may take the their surroundings and what they are doing, presumably
form of speech-related movements, such as lip pressing, to block out the pain and negative experience associated
lip pursing, or teeth clenching; extraneous body move- with their stuttering.
ments, such as eye blinking, head jerking, fist clench-
ing, or stamping; or stereotypic speech utterances, such
as interjections, running starts, or circumlocutions, in
KEY ASSESSMENT PARAMETERS
which the speaker uses evasive or wordy substitutions The following sections outline key parameters to be con-
to avoid an anticipated disfluency. According to Guitar sidered in the assessment of a client who stutters. These
(2006, p. 16), accessory behaviors can be described parameters form the basis for many of the formal and
as either escape behaviors or avoidance behaviors. informal measures designed for evaluating stuttering.
Escape behaviors represent the speaker’s attempt to Although the availability of published protocols makes
release him- or herself from the block (e.g., by blink- it possible for clinicians to evaluate stuttering using
ing, moving the head, or stamping the feet). Avoidance standardized materials and scoring, we hope the details
behaviors, on the other hand, are used to circumvent provided in this section will help clinicians understand
the moment of disfluency altogether and may include the basic components from which these measures are
behaviors previously used as escapes or new behaviors derived, as well as the criteria used to arrive at specific
such as substituting words, postponing feared words, or clinical decisions.
using starters. Table 13-2 summarizes these categories Certain components of stuttering disorders, such as
of accessory behaviors. the presence and severity of disfluencies, are relatively
 A S S E S S M E NT OF F L U E NC Y D IS OR D E R S 353

simple to measure and quantify. Other aspects of stut- typically be 36% to 50%. Children who stut-
tering, such as the extent to which an individual may ter, on the other hand, tend to show an aver-
be reacting to his or her disfluencies, may be more dif- age of at least 65% SLDs.
ficult to analyze. Ideally, assessment of fluency must c. What is the specific frequency of within-
examine core behaviors as well as attitudes, perceptions, word disfluencies (or SLDs)? Based on data
and reactions to stuttering. Following is a list of general reviewed by Yairi (1997), we know that pre-
areas explored in most fluency evaluations. When avail- school children who stutter produce at least
able, we include normative data so that clinicians can 3 or 4 SLDs per 100 syllables, whereas non-
determine whether certain behaviors are atypical or not. stuttering children produce fewer than
3 SLDs for the same total number of syllables.
Measurement of Core Behaviors 2. Frequency of disfluencies: Examining the amount
of disfluency present can provide information
Because certain core behaviors are present in the speech about the presence and severity of a stuttering
of fluent speakers, a key clinical question is how to dif- disorder and is usually measured as the number
ferentiate typical disfluencies from those that signify a of disfluencies per 100 words or 100 syllables.
stuttering disorder. This can be accomplished by looking In general, it is preferable to use measurements
at specific characteristics of the core behaviors: based on syllable counts in order to capture
1. Disfluency types: In the section on core behaviors multiple disfluencies that may occur on multi-
(see Table 13-1 for summary), we identified syllabic words and to be able to form accurate
specific types of disfluencies (e.g., phrase repeti- comparisons between disfluency counts obtained
tions, interjections) that are more likely to be during the preschool years, when single-syllable
considered normal disfluencies, and other types words predominate, to later years, when use of
(e.g., sound repetitions, prolongations, blocks, multi-syllabic words increases.
broken words) more likely to be perceived by It is well established that children who stut-
listeners as atypical. Recording the types of dis- ter, as a group, produce more disfluencies than
fluencies observed helps the clinician determine nonstuttering children; however, there tends to
the presence and severity of a stuttering disor- be some degree of overlap between groups. This
der. A useful worksheet is provided later in the fact makes it difficult to differentiate stuttering
section on core assessment procedures. Specific from normal disfluency on the basis of frequency 13
questions to consider: alone. Nevertheless, considerable data for both

FLUENCY DISORDERS
a. Are disfluencies comprised primarily of typi- children and adults who stutter suggest that
cal disfluencies or atypical disfluencies? the presence of more than 10 disfluencies
b. What is the proportion of within-word per 100 words is valid cause for concern (Adams,
disfluencies to between-word disfluencies? 1980; Bloodstein & Bernstein Ratner, 2008;
The same question can be framed using the p. 318; Yairi, 1997; Yaruss, 1998). Similar findings
terms SLDs and other disfluencies (ODs). are reported for frequency counts that are based
How much of the total number of disflu- on syllables rather than words. Yairi (1997), for
encies do the SLDs represent? Occasional example, found an average of 17 disfluencies
SLDs may be present in speech produced by per 100 spoken syllables in preschool children
nonstuttering children; however, the propor- who stuttered, and 19–20 disfluencies per 100
tion of SLDs to ODs will differ significantly syllables in slightly younger children who were
between children who do and do not stutter. closer to the onset of stuttering. In contrast, non-
According to Yairi (1997), the proportion of stuttering children produced only 6–8 disfluen-
SLDs to the total number of disfluencies will cies for the same total number of syllables. Other
354 CHAPTER 13

researchers (e.g., Pellowski & Conture, 2002) 4. Duration of disfluencies: The duration of certain
focus specifically on SLDs and suggest that the disfluencies, such as repetitions, can be mea-
presence of more than 3 SLDs per 100 words sured as the number of reiterations (repetitions
represents incipient stuttering rather than typical beyond the initial production); however, the du-
developmental disfluencies. For additional infor- ration of most other forms of disfluency is de-
mation on counting the frequency of disfluen- scribed as a length of time (typically in seconds).
cies, readers are referred to the sample worksheet According to Bloodstein and Bernstein-Ratner
provided later in this chapter in the section on (2008, p. 3), measurements of duration have
assessment aims and procedures. The worksheet limited usefulness for describing the severity of
is designed for a 100-syllable speech sample; stuttering in adults, as most adults who stutter
however, clinicians can design their own tables to do not vary much from each other in this partic-
accommodate any total number of syllables and ular feature. Nevertheless, duration of disfluency
follow the instructions provided to derive the is recommended by a number of researchers
percentage of stuttered syllables (or percentage (e.g., Yairi & Lewis, 1984) for the differential
of stuttered words). diagnosis of typical versus atypical disfluency
3. Presence of clusters: Clusters are defined as the in young children, and can be quite helpful in
occurrence of two or more disfluencies on the clinical practice. These findings are summarized
same word or utterance (e.g., I-I-I went to in Table 13-3.
the b-b-beach). Several researchers have sug-
gested that clusters may be a useful marker
Observation of Accessory Behaviors
of early stuttering based on studies showing
a much greater prevalence of clusters in the The presence of accessory behaviors reflects the child’s
speech of stuttering children compared to that growing awareness of his or her stuttering and is evi-
of nonstuttering children (e.g., Hubbard & dence of increasing struggle. Most often, accessory
Yairi, 1988; LaSalle & Conture, 1995; Logan & behaviors emerge during the early elementary years
LaSalle, 1999). According to Zembrowski and gradually become part of the child’s chronic stut-
and Kelly (2002), children with three or more tering pattern. Some children, however, display associ-
clusters of disfluencies in a 100-syllable sample ated behaviors as early as 1 month following the onset of
should be considered to be stuttering or “at risk” stuttering (Zembrowski & Kelly, 2002). Either way, the
for stuttering. Recent findings by Robb and presence of these symptoms unequivocally differentiates
colleagues (Robb, Sargent, & O’Beirne, 2009) between typical disfluency and stuttering, as nonstutter-
indicate that disfluency clusters continue to be ing children do not produce secondary characteristics
a feature of stuttering in adults and that the when they are disfluent. To measure these characteris-
frequency of clusters is positively correlated with tics, the clinician must carefully note extraneous behav-
the overall percentage and severity of disfluency. iors that occur specifically during moments of disfluency

Table 13-3. Differentiating Incipient Stuttering and Normal Disfluency Based on Duration.

DISFLUENCY Incipient Stuttering Normal Disfluency Reference

Within-word repetitions More than 2 reiterations Fewer than 2 reiterations Van Riper (1982),
(sound, syllable, or single- (e.g., “b-b-b-ball”) (e.g., “b-ball”) Adams (1980),
syllable words) Curlee (1999),
Yairi & Lewis (1984)
Prolongations Longer than 1 second Less than 1 second
© Cengage Learning 2012
 A S S E S S M E NT OF F L U E NC Y D IS OR D E R S 355

(general movements or behaviors that are observed dur- “iceberg” that is completely hidden from view but that
ing both fluent and nonfluent speech production, such may be a powerful negative force within the person who
as nervous tics or habits, are excluded). Accessory behav- stutters. In such situations, a diagnosis of stuttering may
iors may include one or more of the following: be based on the individual’s perception of him- or her-
● closing eyes self as a person who stutters and the shame, anxiety,
● blinking rapidly fear, and avoidance behaviors that typically accompany
● squeezing eyes shut this perception. For further information related to the
● looking around evaluation of covert symptoms associated with stutter-
● moving eyes vertically or laterally ing, please see the following discussion on assessment of
● consistent loss of eye contact psychological reaction and avoidance behaviors.
● throwing head back
● torso or limb movements Assessment of Variability
● foot, hand, or finger tapping An important, and sometimes confusing, aspect of stut-
● audible inhalation or exhalation tering is the inconsistencies with which symptoms are
● gasping observed, particularly in young children. Near onset, par-
● visible tension around face or mouth ents will often report that the child’s stuttering “comes
● facial grimacing and goes” or that it fluctuates in severity, depending on
● lip pursing or pressing a variety of factors, such as the child’s fatigue, level of
● tongue clicking excitement, familiarity with the listener, or other specific
● sudden changes in vocal pitch, loudness, or quality characteristics related to the setting or the nature of the
● word substitutions or circumlocutions interaction. To some degree, fluctuations in disfluency
● stalling are typical for all individuals who stutter; however, it
It is important to keep in mind that stuttering can is helpful to determine the extent to which the disor-
sometimes be almost entirely covert, with no observ- der may vary in a particular speaker and whether there
able symptoms at all. In such situations, the person are specific factors or situations that precipitate greater
who stutters has become so adept at substituting words fluency or disfluency. Perhaps most critical is to estab-
and avoiding disfluencies that he or she doesn’t actu- lish whether the level of disfluency observed during an
ally appear to be stuttering. This is the portion of the evaluation is typical for that individual. In Table 13-4, 13
Table 13-4. Sources and Examples of Variability.

FLUENCY DISORDERS
SOURCES OF VARIABILITY Examples
Setting Home, clinic, school
Speaking task Free-play, play with pressures imposed, story retell, picture description, monologue,
dialogue, reading
Conversational partner Parent, clinician, friend, teacher, employer, spouse
Number of conversational partners or listeners 1:1 vs. group interaction
Conversational medium In person, over telephone, in the presence of a recording device
Conversation topic Factual vs. personal/emotional
Time Different times of day, weekday vs. weekend, typical schedule vs. vacation
Nature of speaking situation Casual conversation, argument, interview, formal presentation
Source: Based on Yaruss (1997).
356 CHAPTER 13

we list a number of factors associated with variability in the chapter, we present references and details regarding
stuttering severity. Although it is not practical or even specific protocols available for clinical use.
desirable to measure all of these factors, we encourage
you to consider how each potential source of variability Assessment of Locus of Control
may affect specific clients and to measure this variability of Behavior (LCB)
directly when appropriate. A concept closely related to attitudes and perception is
Assessment of Psychological Reaction that of locus of control of behavior (LCB). This idea was
popularized by social psychologist Julian Rotter through
and Avoidance Behaviors
his development of a published scale (1966) to measure
Most people with chronic forms of stuttering gradu- this construct. His original scale has since been adapted
ally begin to try avoiding disfluencies. Paradoxically, to evaluate perceptions of control in people who stut-
the struggle to avoid stuttering only serves to inten- ter (e.g., Locus of Control of Behavior Scale developed
sify the disorder by adding layers of accessory behav- by Craig, Franklin, & Andrews, 1984). Locus of control
iors and anxiety that can become quite pervasive. Many refers to the extent to which an individual attributes the
theories of stuttering, such as Bloodstein’s anticipa- outcome of events to external circumstances, such as luck,
tory struggle hypothesis (Bloodstein, 1995, pp. 63–67), coincidence, and environmental factors, versus internal
emphasize the ways in which negative perceptions and factors, such as personal abilities and effort. In general,
beliefs exacerbate and complicate stuttering disorders. individuals who locate control outside of themselves
Even individuals with mild forms of stuttering may believe that they have less control over their fate and tend
react significantly to disfluencies, showing very negative to be more stressed and depression-prone as a result.
attitudes about their stuttering, extreme forms of self- Numerous researchers have examined LCB in people
criticism, and hypervigilance about their speech pro- who stutter with somewhat equivocal findings. First, it is
duction (Leith, Mahr, & Miller, 1993). Gaining insight unclear whether people who stutter actually differ from
into these beliefs and attitudes is therefore an integral nonstutterers in LCB, particularly when measuring over-
component of the diagnostic process. all LCB rather than locus-of-control beliefs related spe-
Over the past several decades, many different pro- cifically to speech production (McDonough & Quesal,
tocols have emerged to help clinicians examine differ- 1988). Moreover, LCB scores may not be associated with
ent attitudinal and emotional reactions to stuttering. treatment outcome in any predictable way (Ladouceur,
Although there is no single instrument that provides Caron, & Caron, 1989), although certain researchers
a comprehensive assessment of all the possible psycho- have provided evidence to the contrary (e.g., Craig &
logical sequelae of stuttering, each protocol will help Andrews, 1985). Nevertheless, one’s belief that he or she
clinicians learn about specific ways in which a client is a victim of stuttering and has no control over the dis-
may perceive and feel about his or her stuttering, com- order is certainly an important assumption to be aware
municative abilities, and social situations in general. of and to examine in fluency assessment. Table  13-6
Table 13-5 lists some of the broad areas considered in shows several statements and questions drawn from the
these scales with sample questions that might be pre- Mastery-Powerlessness Scale (Hoehn-Saric & McLeod,
sented to the person who stutters, often in written form. 1985, as cited by Leith et al., 1993). Additional protocols
Typically, scales are developed by administering sets for evaluating LCB in people who stutter are listed in
of questions or statements to both people who stutter Table 13-14 later in this chapter in the section on formal
and people who do not. Participants indicate whether and informal assessment measures. For further infor-
individual statements or questions are characteristic of mation about LCB and how the clinician can facilitate
them. Comparing these responses provides the basis for its shift from an external to internal source, please see
determining the profiles that contain the typical char- Chapter 2, Counseling and the Diagnostic Interview for
acteristics associated with those who stutter. Further in the Speech-Language Pathologist.
 A S S E S S M E NT OF F L U E NC Y D IS OR D E R S 357

Table 13-5. Measuring Psychological Reaction to Stuttering.

PSYCHOLOGICAL REACTION
TO STUTTERING Sample Statements and Questions
Expectancy (anticipating difficulty) • Do you help yourself get started talking by laughing, coughing, clearing your throat, or gesturing?
• Do you anticipate difficulty on particular words or sounds?
• Do you repeat a word or phrase preceding the word on which stuttering is expected?
• Do you substitute a different word or phrase for the one you intended to say?
• Do you make your voice louder or softer when stuttering is expected?
• Do you whisper words to yourself or practice what you will say before you speak?
Attitudes about communication and • I usually feel that I am making a favorable impression when I speak.
perceptions of self as a communicator • It is easy to speak with anyone.
• I socialize and mix with people easily.
• My speaking voice is pleasant.
• I have confidence in my speaking ability.
• I dislike introductions.
• I cannot speak to aggressive people.
• People’s opinions about me are based primarily on how I speak.
• How much does stuttering interfere with your sense of self-worth or self-esteem?
Avoidance • Do you respond briefly to questions, using as few words as possible?
• Do you withdraw from situations requiring verbal participation?
• Do you avoid use of the telephone?
• Do you give excuses to avoid talking (e.g., feigning fatigue or lack of interest in topic)?
• Do you ask others to speak for you in difficult situations (e.g., have someone order food for
you in a restaurant)? 13
• Do you use gestures as a substitute for speaking (e.g., nodding your head instead of saying

FLUENCY DISORDERS
“yes” or smiling to acknowledge a greeting)?
Social anxiety or phobia • I’m of no use in the workplace.
• People will think I’m incompetent.
• I’m hopeless.
• People will think I’m strange.
• Everyone will think I’m an idiot.
• No one would want to have a relationship with someone who stutters.
• I embarrass the people I speak with.
• People will laugh at me.
• Everyone hates it when I start to speak.
Source: Sample questions and statements drawn from: Perceptions of Stuttering Inventory (Woolf, 1967); Unhelpful Thoughts and Beliefs about Stuttering (UTBAS) Scale
(St. Clare et al., 2009); S-24 Scale (Andrews & Cutler, 1974); Overall Assessment of the Speaker’s Experience of Stuttering (Yaruss & Quesal, 2006).
358 CHAPTER 13

Table 13-6. Sample Questions and Statements to Assess LCB.

LOCUS OF CONTROL SCALE:*

• If you had a job that did not have automatic pay raises, would you: (1) ask for one when you thought you deserved it
or (0) wait until it was offered to you?
• When you have an accident at home or at work do you usually blame it on: (0) bad luck or the carelessness of others
or (1) your own negligence?
• At a social gathering, who usually takes the lead in choosing the topics of conversation? (0) the person I’m talking with or (1) myself.
• If you were driving in a strange city and got lost, would you first: (1) look at a map and try to figure it out yourself or (0) pull into a gas
station and ask for directions?
• Choose the statement that is closest to what you believe: (0) What is going to happen will usually happen, no matter what I do.
(1) Taking definite actions has usually worked out better for me than trusting fate.
Source: Sample items drawn from the Mastery-Powerlessness Scale (Hoehn-Saric & McLeod, 1985, as cited by Leith et al., 1993).
*Low score indicates external LCB; high score indicates internal LCB.

Measurement of Speech Rate 1. Use graph paper or a table that you have pre-
pared with a predetermined number of cells;
Speech rate may reflect the severity of an individual’s place a dot in individual cells for each syllable or
stuttering, with severe forms of stuttering often result- word that is spoken.
ing in significant reductions in speaking and reading 2. Use a commercially available counter that can be
rate (e.g., Bloodstein, 1995, p. 7). Very rapid speech pressed rapidly for each spoken syllable or word.
rates, particularly when accompanied by irregular 3. Press a specific key on a standard keyboard for
pacing, may also indicate the presence of a cluttering each syllable spoken. (A separate key can be
rather than stuttering disorder. Speaking rate is typi- used simultaneously to indicate moments of
cally measured as the number of either syllables or disfluency.)
words produced per minute, with syllable counts being 4. Using a standard calculator, press 1! for the
the preferred method (see earlier discussion on count- first syllable, then continue pressing the "
ing the frequency of core behaviors or refer to Guitar, button for each subsequent syllable to keep
2006, pp. 193–194, for more detail). All disfluencies a running total.
are included in the speaking time total; however, extra 5. Regardless of the counting method, a stopwatch
repetitions of phrases, words, or syllables are excluded should be used to obtain a precise measure-
from the syllable count so that the final syllable total ment of the total length of time for the speech
reflects only those syllables in which meaningful infor- sample. If speaking rate is being measured dur-
mation is being conveyed to the listener. For example, ing conversation, the stopwatch must be stopped
“My-my-my name is, um, Da-Da-David” would be for turns taken by participants other than the
counted as five syllables. A related measure, known as speaker of interest. To measure articulatory rate,
articulatory rate, focuses specifically on fluent speech. the stopwatch must be stopped during disfluent
Analysis of articulatory rate includes only syllables speech and during pauses so that only continu-
that are produced fluently, excluding all disfluencies, ous runs of fluent speech are being considered in
long pauses, and the time during which these occur. the final results.
Following are several suggestions (based on Guitar,
2006, p. 194; Riley, 2009) to make the task of syllable Results of speaking rate calculations are interpreted
counting as efficient and accurate as possible: with reference to normative data reported for specific
 A S S E S S M E NT OF F L U E NC Y D IS OR D E R S 359

age groups and speech contexts. Tables 13-7, 13-8, and Assessment of Environmental Demands
13-9 list expected speaking and reading rates for fluent and Expectations
individuals based on the findings of several studies.
Many theorists have discussed the role of the envi-
ronment in the development of stuttering disorders.
Table 13-7. Speaking Rates for Fluent Speakers. Wendell Johnson’s original notion that stuttering may
(syllables per minute) by Age. begin “in the parent’s ear” has been largely discredited
(Meyers, 1986; Yairi & Lewis, 1984); however, this idea
AGE (YEARS) Range (spm)
set the stage for other hypotheses that have been more
3 116–163 widely accepted and that have inspired specific clinical
4 117–183 approaches to stuttering intervention. Sheehan (1970,
5 109–183 p. 286) believed that children who stutter have probably
had too many demands placed on them while receiving
6 140–175
too little support to meet those demands. The “Demands
8 150–180 and Capacities” model (Starkweather & Gottwald,
10 165–215 1990) similarly attributes stuttering to an imbalance
12 165–220
between a child’s developing capacities in skill areas
required for communication and the demands, stan-
Adults 162–230
dards, or expectations imposed on the child by his or
Source: Based on Pindzola, Jenkins, & Lokken (1989) and Guitar (2006, p. 193).
her environment. Environmental demands may take the
form of rapid questioning, frequent interruptions, use of
Table 13-8. Range of Speaking Rates (words per minute) overly complex sentences or vocabulary, impatience with
in Fluent Speakers by Context. developmentally typical disfluency, or high standards for
AGE GROUP Context Range (wpm)
achievement and performance in general. These sorts of
challenges are alluded to in Marty Jezer’s (1997) book
Children (7–11) Conversation 92–161*
about his own stuttering, in which he writes: “To be
Children (7–11) Narrative 87–178** heard I had to force my way into a conversation (some-
Adults Conversation 116–164 thing I rarely had the confidence to do) and then say
what I had to say as fast as I could in order not to be 13
Adults Monologue 114–173
interrupted.” Interestingly, a recent longitudinal study
Adults Reading 148–190 reported by Reilly and colleagues (2010) has identified

FLUENCY DISORDERS
Source: Based on Andrews & Ingham (1971), Shapiro (1999 pp. 395–396), and Sturm &
Seery (2007).
higher levels of maternal education as a predictive factor
* Rate in wpm: 109–195. for the emergence of stuttering before age 3, which sug-
** Rate in wpm: 100–216. gests that parents’ standards may be influenced by their
own educational experiences and achievements and that
these standards may be either implicitly and/or explic-
Table 13-9. Average Speaking Rates (words per minute)
for Fluent Adults by Age and Context. itly relayed to very young children.
Environmental pressures can be evaluated by con-
Conversation Monologue Reading sidering 7 specific questions on p. 14 (see Guitar, 2006,
AGE (wpm) (wpm) (wpm)
pp. 241–242, and Starkweather & Givens-Ackerman,
21–30 182.7 151.4 219.9 1997, pp. 91–92, for further details). These factors are
45–54 153.7 133.7 182.1 most often discussed with relation to young children
55–64 168.7 141.7 190.1 who stutter; however, many remain relevant for older
Based on Duchin & Mysak (1987).
children, adolescents, and adults.
360 CHAPTER 13

1. What is the speaking rate of the parents or Related Measures

other significant speakers in the child’s environ-
ment? How do these rates compare to the rate As for most speech and language disorders, assessment
of the child’s speech? (There is no established of fluency involves not only consideration of features
norm for measuring the difference between the related directly to stuttering but also evaluation of other
speaking rates of a child and adults in the child’s systems and abilities that contribute to the production
environment; however, Zebrowski and Kelly of speech. These include:
[2002] suggest that a difference of 100 syllables ● Oral motor strength, coordination, and control:
per minute may be significant.) Adults, too, Measures of articulatory control and diado-
are affected by the speech rate of their listeners chokinetic rate may help the clinician rule out
and will often report more difficulty speaking speech production difficulties related to dys-
when conversational partners use a particularly praxia or apraxia. Assessment of oral motor
rapid rate of speech (Starkweather & Givens- function can also provide important information
Ackerman, 1997, pp. 91–92). about the speaker’s ability to control articula-
2. Do parents use overly complex sentences or dif- tory structures in the absence of verbal demands
ficult vocabulary when speaking with the child? (i.e., in simple speech contexts such as isolated
Young children who stutter may be more likely sounds or syllables). For more information on
to persist when parents use syntax or vocabulary this topic, please see Chapter 6, Assessment of
that is beyond the child’s level (e.g., Kloth et al., the Oral-Peripheral Speech Mechanism.
1999). ● Receptive and expressive language skills: Just as
3. How do parents react to the child’s disfluency? rapid growth in the verbal system accounts for
Are they supportive or critical? Empathetic or normal disfluency in typically developing chil-
anxious? For an older individual who stutters, dren, persisting difficulties in receptive and/or ex-
how do teachers, employers, or colleagues react? pressive language may contribute to or exacerbate
4. What type of communication style is used by stuttering disorders (Anderson & Conture, 2000).
the child’s family or in the adult speaker’s work- Difficulties with word retrieval and sentence for-
place? Are there frequent interruptions, mulation, in particular, can cause disfluencies in
or is there consistent turn-taking during speech production (Boscolo, Bernstein Ratner, &
conversations? Rescorla, 2002), but may not represent a stutter-
5. What is the general atmosphere of the house- ing disorder at all and would require a very dif-
hold? Is it typically rushed and busy, or is it ferent type of treatment approach. Additionally,
relaxed and calm? Is there a consistent daily cluttering disorders often involve difficulties in
schedule, or is there frequent change and lack organizing and formulating thoughts, whereas
of predictability? stuttering disorders do not (Van Zaalen, Wijnen, &
6. Is the individual often in social situations that De Jonckere, 2009). The presence of deficits
involve significant time pressure (e.g., order- within the language system, therefore, can be an
ing in a store or restaurant where customers important consideration for differential diagno-
are waiting behind him or her, speaking to sis. For a complete discussion on the evaluation
customer-service representatives over the of language disorders, please refer to Chapter 8,
telephone)? Assessment of Preschool Language Disorders,
7. Does the family have very high standards for and Chapter 10, Assessment of School-Age
academic, athletic, social, or verbal performance? Language/Literacy Disorders.
Does the child feel inadequate in comparison to ● Articulation and overall speech intelligibility:
his or her siblings? Careful assessment of articulatory rate, accuracy,
 A S S E S S M E NT OF F L U E NC Y D IS OR D E R S 361

and intelligibility is critical for differential diag- and to measure maintenance of fluency following the ter-
nosis of cluttering and stuttering. Rapid and/or mination of treatment. Shenker further encourages the
irregular articulatory rate is a key feature of clut- establishment of self-measurement as a specific treatment
tering, as are excessive coarticulations (deletion goal. Training clients to measure their own outcomes and
of sounds or syllables in multi-syllabic words), overall success can facilitate their acceptance of responsi-
indistinct articulation, and reduced overall bility for treatment, and help them become more active
speech intelligibility (St. Louis, Myers, Bakker, participants in the therapeutic process.
Klass, & Raphael, 2007). Differential diagnosis Certain general procedures form the basis for all flu-
of stuttering and cluttering is considered in ency evaluations, regardless of the client’s age:
more detail later in this chapter. Further infor- ● Case history: Before beginning any evaluation,
mation on the assessment of articulation can be it is essential to obtain background information
found in Chapter 7, Assessment of Articulation related to prenatal and birth circumstances, fam-
and Phonological Disorders. ily structure, general motor and speech-language
● Voice: Basic aspects of vocal function, such as development, academic performance, social his-
vocal intensity, pitch, and quality, should be tory, medical/surgical history, and employment
considered and can typically be evaluated infor- information, if relevant. It is helpful to mail
mally using the same speech samples obtained paperwork to parents or clients and have them
for fluency analyses. Readers are referred to send this information back prior to the sched-
Chapter 12, Assessment of Voice Disorders, for uled evaluation so that you can form certain
further information on this topic. expectations and prepare accordingly.
● Hearing: A basic hearing screening should be ● Interview the parent and/or client: The inter-
included in all standard speech and language view provides clinicians with the opportunity
evaluations. For more information, please see to review the case history, obtain a general
Chapter 5, The Audiological Screening for the impression of the client, and explore questions
Speech-Language Evaluation. that can provide important information about
● Nonverbal intelligence: Assessment of intel- the stuttering and its effect on the client’s life.
ligence is not typically included in fluency Sample questions are provided later in the
assessment; however, higher nonverbal IQ is as- chapter in the sections covering assessment
sociated with greater likelihood of spontaneous for specific age groups. 13
recovery from early stuttering (Yairi, Ambrose, ● Direct interaction with the child, teen, or adult in

FLUENCY DISORDERS
Paden, & Throneburg, 1996) and may be a order to obtain speech samples for further anal-
useful prognostic indicator, particularly when ysis: This may be accomplished through sponta-
evaluating preschool children. neous play, structured speech tasks, and/or
conversation and is discussed in more detail for
ASSESSMENT AIMS specific age groups later in the chapter.
Recording speech samples: Video recording is
AND PROCEDURES
●
strongly recommended for all fluency evalua-
The primary aim of assessment is usually to determine tions in order to capture both core stuttering
the presence of a disorder, as well as to describe the nature behaviors as well as accessory behaviors, and to
and severity of the problem prior to initiating treatment. ensure precise quantification of these symptoms.
In addition to these goals, Shenker (2006) emphasizes Significant differences have been reported be-
the importance of using continuous outcome measures tween severity ratings based on audio recordings
in order to monitor progress while a client is in therapy versus audio-visual recordings, with audio-based
362 CHAPTER 13

ratings being much less reliable and tending to Results can then be organized to reflect the fre-
underestimate the frequency of disfluencies and quency of each disfluency type and relative proportion
related symptoms (Rousseau, Onslow, Packman, & of within-word to between-word disfluencies.
Jones, 2008). Use of video samples can also be
an extremely effective way to help clients un-
derstand, monitor, and measure their stuttering Within-Word Between-Word
behaviors. Disfluencies Disfluencies
● Informal analysis of stuttering behaviors: Word repetitions 3 Phrase repetitions: 2
Experienced clinicians may be able to perform (single syllable):
real-time analysis of disfluency counts, using Syllable repetitions: 1 Word repetitions 0
prepared charts and forms that are based on (multi-syllabic):
clinic-specific methods. This form of analysis Sound repetitions: 2 Revisions: 0
can also be completed later by reviewing re-
Prolongations: 6 Interjections: 2
corded speech samples obtained during the
evaluation. Examples and details related to Blocks: 5
such methods can be found in Yaruss (1998). Total within-word 17 Total between-word 4
Following is a sample form to demonstrate disfluencies: disfluencies:
analysis of disfluencies in 100 syllables.
100-syllable sample: Place a dot in one box for each Informal analyses may also involve computing
fluent syllable or word spoken. Use the following abbre- speaking rate, percent of stuttered syllables, and spe-
viations to indicate disfluencies. (Multiple reiterations cific proportions represented by each type of disfluency.
of the same disfluency can be noted, e.g., by placing a These calculations will require the use of a stopwatch,
superscript above the symbol, such as R-p2, but should as well as some method for counting syllables and time
not be indicated by multiple abbreviations in separate (in seconds), as discussed earlier in the sections on
boxes.): counting frequency of disfluencies and the section on
measuring speaking rate. Use of an Excel spreadsheet
R-p (phrase repetition) P (prolongation) with basic formulas may simplify the task of deriving
R-w (whole-word repetition) B (block) an overall percentage of syllables stuttered (%SS) as
R-sy (syllable repetition) I (interjection) well as individual frequencies (expressed in %SS) for
R-sd (sound repetition) R (revision) each disfluency type and disfluency category (within-
vs. between-word), which may be required for certain
R-w • • • • B • B • •
assessment protocols. A sample table may be organized
• R-sy • • B • • • • • as follows:
• • • • • R-p P • • • ● Use of formal and informal assessment mea-
• • P • • • • R-sd • R-w sures to quantify symptoms and rate stuttering
• • • • I • • • • •
severity: Many scales and protocols have been
published to measure specific aspects of stutter-
R-sd • • P • • I • • •
ing behavior, describe psychological reactions
• B • • • • • • • R-p to stuttering, and predict stuttering chronicity.
• • • • B • • R • • These are listed and described in further detail
later in this chapter in the section “Formal and
• P • • • • • • • •
Informal Assessment Measures for Stuttering
• • P • • R-w • • P • Disorders on p. 25.”
 A S S E S S M E NT OF F L U E NC Y D IS OR D E R S 363

Disfluency type Total Within Between %SS As a child with stuttering matures, we see changes in
the specific types of disfluencies that predominate, as
Phrase repetition 0 0 0
well as emergence of physical tension and accessory
BETWEEN-WORD

Word repetition 5 5 1.67 behaviors; development of negative attitudes, emotions,

(multisyllabic)
and self-perceptions; and, often, an increasing assort-
Interjections 2 2 0.67 ment of avoidance behaviors and situational fears (see
Running start 3 3 1 Guitar, 2006, pp. 137–169, for details on the develop-
Revision 1 1 0.33 ment of stuttering disorder). The assessment process
Word repetition 6 6 2
varies somewhat based on the individual’s age and the
(single syllable) level to which his or her stuttering has progressed.
Syllable repetition 4 4 1.33
WITHIN-WORD

Sound repetition 5 5 1.67

ASSESSMENT
Sound
prolongation
3 3 1
OF PRESCHOOL CHILDREN
Block 5 5 1.67 The evaluation of stuttering in preschool children is
Broken word 0 0 0
driven by two key questions: (1) Is this child stuttering—
that is, are the child’s disfluencies developmentally typi-
Totals 34 23 11 11.33
cal or do they represent a stuttering disorder? (2) If the
Category % 67.65 32.35 child is stuttering, is the disorder likely to be outgrown
% SS 11.33 7.67 3.67 naturally, or is it more likely to persist?
Syllable number 300 The clinician will typically begin by interviewing the
child’s parent(s) or guardian and reviewing background
● Stimulability testing: An important part of the information provided. During this interaction, the cli-
assessment process is determining the client’s nician may seek answers to specific questions regarding
responsiveness to specific treatment techniques the nature and history of the fluency disorder but should
that are demonstrated by the clinician. A com- also be prepared to listen, answer questions, and provide
plete discussion on the various forms of treat- information. Open-ended questions are generally the
ment available for stuttering is beyond the scope most effective means of learning about the child, the
of this chapter; however, the evaluation should child’s environment, and the stuttering problem. Initial
13
involve brief trials of strategies such as easy on- questions may consist of the following:

FLUENCY DISORDERS
sets, continuous phonation, or pull-outs for older ● Tell me about your child’s speech; what are your
children and adults; and slow, relaxed forms of concerns?
speaking for young children. Clients may express ● Describe your pregnancy with this child. Were
a preference for certain methods over others, may there any complications during the birth?
be able to imitate certain techniques more easily ● How would you describe this child’s motor
than others, or may be able to imitate techniques development?
only in specific speech contexts (e.g., single words ● What was the child’s early speech and language
beginning with vowels). These considerations are development like? Does the child have any diffi-
essential for effectively bridging assessment find- culties producing specific sounds, understanding
ings to practical treatment planning. what others are saying to him or her, or express-
Remaining sections in this chapter are subdivided by ing him- or herself?
age group because stuttering disorders tend to evolve in ● Is there any family history of stuttering or other
fairly predictable ways over the course of development. speech-language problems?
364 CHAPTER 13

Additional inquiries may focus more specifically on management recommendations. Reported concerns about
the child’s disfluencies: speech and language development would clearly indicate
the need for more in-depth assessment of these skill areas
● How does the stuttering sound? Can you de-
and the ways in which language difficulties may be inter-
scribe or demonstrate it?
fering with the child’s ability to express him- or herself
● When were disfluencies first noted? How did
fluently. Finally, reports of emotional trauma, motor dif-
the disfluencies sound at that time? Have the
ficulties, or academic problems may indicate the need
disfluencies changed since then?
for referrals to other professionals in order to clarify the
● Was anything unusual occurring in the child’s
nature of the fluency disorder and its potential causes.
life at the time of onset? Was anything going on
To evaluate fluency in young children, clinicians
in the family or at school?
typically arrange two types of interactions: one in which
● Does the child seem aware of his or her stutter-
the clinician observes parents or guardians interacting
ing in any way? If so, how does he or she react?
with the child, and one in which the clinician interacts
● Does the child ever avoid speaking due to dis-
with the child directly. Parent–child interaction involves
fluencies? Does the child ask others to speak for
10–15 minutes of natural play or conversation and pro-
him or her, and say “forget it,” or change a word
vides an opportunity for the clinician to observe whether
when it is difficult?
there are specific communicative behaviors contributing
● Describe the child’s personality: Is he or she
to the child’s disfluencies. These may include:
sensitive, anxious, timid, and introverted, or
more self-confident, resilient, and outgoing? ● frequent interruptions
● What is the family structure? Are there siblings? ● high proportion of questions versus comments
How does the child relate to them? ● use of rapid speaking rate
● What is the child’s schedule like? Are there ● use of complex vocabulary
situations or settings that seem to make the ● use of lengthy and/or syntactically complex
stuttering worse or better? sentences
● What is the atmosphere like at home? Is it fast- ● asking a second question before the initial one
paced, stressful, or noisy? Are there often several was answered
people talking at once? ● poor turn-taking
● Do the parents have ideas about what caused ● frequent correction of child’s behavior (verbal/
the problem? nonverbal)
● How do the parents typically react to the child’s ● filling in words or finishing the child’s sentences
stuttering—what do they say or do? The primary aim of the clinician’s interaction with
● Has the child been evaluated or treated? What the child is to obtain a representative speech sample.
advice were the parents given? What was the This may be accomplished through one or more of the
nature of the intervention? following tasks:
Responses to these questions will guide the clini- ● spontaneous speaking during play (e.g., blocks,
cian’s decisions throughout the rest of the diagnos- play figures, dolls, play dough)
tic process. If the child’s fluency is highly variable or ● describing pictures scenes
the child is described as sensitive and shy, the clini- ● telling a story based on a wordless picture book
cian may have parents record multiple speech samples ● narrating a recent event or familiar story
outside of the clinic to supplement the one obtained ● play with pressure: the clinician interrupts,
during assessment. Details about the child’s family and speaks rapidly, challenges or disagrees with the
home environment may indicate the need for more child, and imposes pressure to induce disfluen-
direct observations of these interactions and for specific cies (see Gregory & Hill, 1999, for further detail)
 A S S E S S M E NT OF F L U E NC Y D IS OR D E R S 365

Although speech samples of 300 words or syllables Once speech samples are obtained and key assess-
are often considered adequate for fluency analysis ment parameters have been analyzed, these results can
(e.g., Riley, 2009), it is recommended that clinicians be used by the clinician to determine the presence of a
record longer speech samples (e.g., 600 syllables) stuttering disorder, the severity of the disorder, and its
for preschool-age children, particularly when likelihood to persist. Numerous general criteria are pro-
the child is demonstrating relatively low levels of dis- vided in the literature in addition to various formal and
fluency, as the additional information can be criti- informal protocols to help clinicians with these deci-
cal for correct diagnosis. As demonstrated by Sawyer sions. Following are several examples of these criteria as
and Yairi (2006), the frequency of SLDs tends to well as an overview of the scales and protocols that are
increase for most children as sample sizes become available for this age group.
longer, and a diagnosis of stuttering may be missed According to Guitar (2006, pp. 138–156), young
when only 300 syllables are considered. According to children’s disfluencies can be classified as developmen-
Curlee (1999), the use of word counts is satisfactory tally normal, borderline stuttering, or beginning stutter-
for 2- to 3-year-old children because words produced ing based on the characteristics shown in Table 13-10.
by young children generally do not consist of many Curlee (1999) further describes five potential diag-
syllables; however, syllable measures are preferred nostic conclusions that may be reached as a result of
for children who use a greater percentage (more the young child’s fluency assessment. These profiles
than 25%) of multi-syllabic words. Another impor- (as shown in Table 13-11) may help clinicians integrate
tant factor to consider is the great deal of variability various observations and information from the evalua-
typically present in the stuttering of young children. tion in order to form specific recommendations.
Obtaining several speech samples in different settings Specific results of the child’s speech sample analysis
(e.g., home, preschool, clinic), with different speakers are also used to complete available protocols that can
(e.g., mother, father, clinician), and during different provide information regarding the severity level of the
activities (e.g., spontaneous play, picture description, disfluency and the likelihood that stuttering will persist.
play with pressure) often provides the best represen- A full list of measures used for preschool children and
tation of the child’s typical speaking pattern as well details regarding each measure can be found later in this
as important information about environmental influ- chapter in the section on formal and informal assess-
ences on the child’s fluency levels. ment measures for stuttering disorders. Perhaps the
13

FLUENCY DISORDERS
Table 13-10. Classification of Disfluencies as Normal, Borderline, or Beginning Stuttering.

NORMAL DISFLUENCY Borderline Stuttering Beginning Stuttering

• Fewer than 10 disfluencies per 100 words • More than 10 disfluencies • Disfluencies are marked by tension
• Disfluencies consist primarily of non-SLDs per 100 words • Repetitions are rapid and rushed
• Repetitions consist of 2 or fewer reiterations • Loose, relaxed disfluencies • Rises in pitch during repetitions
• Repetitions are slow and regular in tempo • SLDs and non-SLDs may be present and prolongations
• SLDs comprise less than 50% of the • Repetitions may have • Struggle with airflow or phonation
total disfluencies more than 2 reiterations • Facial tension
• More than 50% of disfluencies • Awareness, possible frustration
are SLDs • May use escape behaviors to terminate
• Clusters may be present blocks (e.g., eye blink)
• Possible avoidance (e.g., word substitution)
Source: Based on Guitar (2006, pp. 138–156).
366 CHAPTER 13

Table 13-11. Disfluency Profiles and Diagnostic Conclusions.

DISFLUENCY PROFILE Conclusion Recommendation

• May be highly disfluent but SLD frequency falls below Minimal/no signs of childhood No intervention or ongoing follow-up needed;
2%–3% of total words or syllables stuttering reassess with any significant change
• No excessive muscle tension or effort
• Normal speech and language skills
• Initial stuttering described as severe; however, Inconsistent signs of childhood Further observation and testing; ensure that
few SLDs present in sample stuttering low frequency of disfluency during evalua-
tion represents child’s typical fluency level
• SLDs on 3%–10% of total syllables/words Signs of childhood stuttering Regular follow-up and monitoring of fluency
present but for less than 1 year for 1 year post-onset; direct intervention
• Accessory behaviors may be present
if no reduction in symptoms over this time
• Evidence of muscle tension during disfluencies
• Emerging awareness of stuttering; may seem frus-
trated when having unusual difficulty
• Symptoms present less than 1 year
• Early signs of stuttering along with possible articula- Evidence of childhood stutter- Direct intervention addressing both
tory, phonological, and/or language disorder ing as well as speech and/or disorders
language problem
• Frequent disfluencies with SLDs present on 15% or Consistent evidence of childhood Immediate intervention
more of total syllables/words stuttering for 1 year or longer
• Tense, effortful disfluencies
• Associated behaviors (e.g., lip tremor, blinking)
• Frustration, avoidance
• Symptoms present for 1 year or more
Source: Based on Curlee (1999).

most commonly used protocol is the Stuttering Severity stuttering based on specific speech characteristics, such
Instrument–4 (SSI-4), recently revised by Riley (2009), as disfluency type, frequency, duration, and the presence
which provides percentile scores and severity ratings of associated behaviors or avoidances. The Stuttering
(mild, very mild, moderate, severe, very severe) based on Prediction Instrument for Young Children (Riley, 1981)
the frequency and duration of core behaviors as well as is a formal measure that provides prognostic informa-
the presence and nature of associated behaviors. When tion about the likelihood of spontaneous recovery. The
used for older children or adults, the SSI-4 combines Behavioral Style Questionnaire (McDevitt & Carey,
samples obtained in both speaking and reading tasks; 1978) is a set of questions administered to parents in
however, normative data is also provided for nonreaders. order to obtain information about the child’s person-
The Pindzola Protocol for Differentiating the Incipient ality. Although this measure does not assess stutter-
Stutterer (Pindzola & White, 1986) can help the clini- ing behaviors directly, it can help the clinician identify
cian determine whether a child’s disfluencies are devel- temperamental traits, such as inhibition and sensitivity,
opmentally typical or more consistent with childhood that may contribute to the development of stuttering
 A S S E S S M E NT OF F L U E NC Y D IS OR D E R S 367

Table 13-12. Factors Associated with Persistent Stuttering versus Spontaneous Recovery.

Associated with Persisting Associated with Spontaneous

Stuttering Recovery
Gender Male Female
Family history Relatives with persisting stuttering No family history of stuttering
Handedness Left-handedness Right-handedness
Speech-language Presence of articulation and/or language difficulties Age-appropriate speech and language abilities
Nonverbal intelligence Low nonverbal intelligence scores High nonverbal intelligence scores
Parental speech Complex language and syntax Short sentences with simple vocabulary
Age of onset Later age of onset Earlier age of onset
Time since onset of disfluencies Disfluencies present 1 year or longer Disfluencies present less than 1 year
Changes in disfluencies No change in SLDs or worsening SLDs 1 year Decreased SLDs within 12–15 months
post-onset post-onset
Escape/avoidance behaviors Presence of accessory behaviors, tension, struggle, No accessory behaviors, tension, struggle, or
word substitutions avoidance
Speaking rate Fast speaking rate Slower speaking rate
Based on data from: Brosch et al., 1999; Curlee, 1999; Kloth et al., 1999; Rommel et al., 2000; Yairi et al., 1996; Yairi & Ambrose, 1999.

in young children (see Guitar, 2006, pp. 122–132, for by or reacting to his or her stuttering? (4) What forms
further detail). of treatment may be most appropriate?
Numerous factors have been associated with greater For this age group, information about the stuttering
likelihood of either chronic stuttering or natural recov- can be obtained not only from the child’s parents but
ery (e.g., Brosch, Haege, Kalehne, & Johannsen; Curlee, also from the child him- or herself and, if possible, from
1999; Kloth et al., 1999; Rommel, Hage, Kalehne, & classroom teachers. As with most interviews of this
Johannsen, 2000; Yairi et al., 1996; Yairi & Ambrose, nature, open-ended questions are often most effective,
1999). These should be carefully considered by the clini- with more specific inquiries as necessary. The following
13
cian and are outlined in Table 13-12. questions are provided as guidelines.

FLUENCY DISORDERS
Child Interview
ASSESSMENT
Do you find it difficult to speak? What usually
OF SCHOOL- AGE CHILDREN
●
happens?
Assessment of the school-age child includes most of ● How often does this happen? Does your speech
the same procedures used for the preschool child, with usually sound the same or does it sound differ-
several considerations and modifications. First, it is ent at different times?
important to remember that disfluencies at this stage ● Is it more difficult to speak in certain situations
in development are no longer likely to be spontaneously than in others?
outgrown (Guitar, 2006, p. 246). The key questions ● Are certain words or sounds more difficult than
guiding the evaluation are therefore: (1) Is this child others?
stuttering? (2) If so, what is the nature and severity of ● Do you ever avoid speaking because of the way
the stuttering? (3) To what extent is the child affected you sound?
368 CHAPTER 13

● How do other people react to your speech? Unlike preschoolers, school-age children are able
● How does your speech make you feel? to provide samples of their speech in both speaking
● Do you use any “tricks” to get hard words out? and reading tasks, and separate analyses of stuttering
behaviors and speech rates are completed for each con-
Parent Interview text. Speaking tasks for this age group should include
● How is your child doing academically? Socially? both monologue (e.g., retelling a book/movie, describ-
● Does your child avoid any speaking situations ing recent events, describing sequenced picture cards)
because of his or her stuttering? and dialogue. Reading samples are based on reading
● Does he or she feel ashamed? Is he or she being material below the child’s reading level to ensure that
teased? disfluencies are due to stuttering rather than decoding
● Has your child learned any strategies to manage difficulties. The SSI-4 (Riley, 2009) includes reading
his or her stuttering? samples at the third-, fifth-, and seventh-grade levels
that can be used for this purpose. Additional measures
Teacher Interview for determining the presence and severity of stuttering
● Does the child participate in class? in school-age children can be found in Table 13-13 and
● Is he or she teased by classmates? in the following section on formal and informal assess-
● How do you typically react to the child’s ment measures for stuttering disorders.
disfluencies?

Table 13-13. Measures and Scales for Preschool and/or School-Age Children Who Stutter.

MEASURE/SCALE Author/Publisher Age Behaviors Assessed

Overall Assessment of the Speaker’s Yaruss, Coleman, & Quesal (2010) 7–12 Perception of stuttering; reactions
Experience of Stuttering–School to stuttering; impact of stuttering
Age (OASES-S) on communication and quality of life
A-19 Scale for Children Who Stutter Andre & Guitar, 2006 School age Attitudes about communication
(cited and available in Guitar, 2006)
Behavioral Style Questionnaire (BSQ) McDevitt & Carey (1978) 3–7 Temperamental characteristics in
children (based on parent report)
Behavior Assessment Battery (BAB): Vanryckeghem & Brutten (2007a); 6–15 Anxiety ratings for different situa-
combination of Behavior Checklist, available through Plural Publishing tions; coping responses for dealing
Communication Attitude Test, and with disfluencies; attitudes toward
Speech Situation Checklist communication
The Behavior Checklist (BCL) Vanryckeghem & Brutten (2007a); avail- School age Coping responses of the child
able through Plural Publishing (part of BAB)
CALMS Rating Scale for School-Age Healey, Scott-Trautman, & Susca (2004) School age Cognitive, affective, linguistic,
Children Who Stutter motor, and social (CALMS) factors
Communication Attitude Test (CAT) Brutten & Dunham (1989); revised version School age Speech-related attitudes
by Vanryckeghem & Brutten (2007a); avail-
able through Plural Publishing (part of BAB)
Communication Attitude Test Vanryckeghem & Brutten (2007b); avail- Preschool Communication attitudes
for Preschool and Kindergarten able through Plural Publishing and kindergar-
Children Who Stutter (KiddyCAT) ten children
 A S S E S S M E NT OF F L U E NC Y D IS OR D E R S 369

Table 13-13. (Continued)

MEASURE/SCALE Author/Publisher Age Behaviors Assessed

The Cooper Chronicity Prediction Cooper & Cooper (1985) Preschool Predicts children who will recover
Checklist with and without treatment
Crowe’s Protocols Crowe, DiLollo, & Crowe (2000) Children, Affective, behavioral, and cognitive
adolescents, aspects of stuttering; stuttering
adults severity; stimulability
Pindzola Protocol for Differentiating Pindzola & White (1986) Preschool Frequency, type, and duration
the Incipient Stutterer of disfluency; audible effort; rhythm
and rate; secondary behaviors;
awareness and reaction
Rosenberg Self-Esteem Scale (RSE) Rosenberg (1979) Grade 5 and up Self-esteem
The Speech Situation Checklists Vanryckeghem & Brutten (2007a); avail- School age Emotional reactions to disfluencies
(SSC-ER and SSC-SD) able through Plural Publishing (part of BAB)
Stuttering Prediction Instrument Riley (1981); published by Pro-Ed 3–8 Core stuttering behaviors and
for Young Children (SPI) reactions; used to rate severity and
predict chronicity
Stuttering Severity Instrument–4 Riley (2009); published by Pro-Ed 2;10–adult Frequency and duration of disfluen-
cies; physical concomitants
© Cengage Learning 2012

Although some information about the child’s atti- behaviors. Information can be obtained through tele-
tudes and feelings may emerge from the case history, phone conferences, meetings, or through written scales
interview, and speaking tasks, the clinician may want and forms, such as the Teachers Assessment of Student
to measure this aspect of stuttering more directly using Communicative Competence (Smith, McCauley, &
paper-and-pencil tasks. Various measures have been Guitar, 2000), in which teachers rate the child’s com-
developed to assess children’s perceptions of their stut- municative functioning in the classroom.
tering, psychological reaction to stuttering, and avoid- As for preschool children, stimulability testing is
ance behaviors. Most are developed based on responses an important part of the evaluation for this age group. 13
that have been found to differentiate children who stut- Brief trials of stuttering modification techniques and

FLUENCY DISORDERS
ter from fluent peers (e.g., De Nil & Brutten, 1991) simple fluency shaping strategies can be attempted to
and provide normative data for each group. Several determine which treatment approach may be better
sample measures for this age group include the A-19 suited for a particular child.
Scale (Guitar & Andre, as cited in Guitar, 2006), the
Communication Attitude Test (CAT; Brutten &
Dunham, 1989; revised by Vanryckeghem & Brutten, ASSESSMENT OF ADOLESCENTS
2007b), and the Overall Assessment of the Speaker’s
AND ADULTS
Experience of Stuttering–School-Age (OASES-S)
(Yaruss, Coleman, & Quesal, 2010). A full list of avail- Adolescents and adults with stuttering disorders typically
able protocols for measuring attitude, perceptions, and have an extensive history of stuttering; the key diagnos-
LCB in school-age children is provided in the following tic questions for individuals in this age group are usually
section on formal and informal assessment measures. not concerned with whether a stuttering disorder exists,
Reports from teachers can also be useful in determining but rather: (1) What is the nature and severity of this
a child’s reactions to stuttering and possible avoidance individual’s stuttering? (2) How severely is this individual
370 CHAPTER 13

reacting to his or her stuttering? (3) What specific fears As described for preschool and school-aged chil-
or avoidance behaviors are present? (4) How has stutter- dren, the clinician can use a combination of formal and
ing affected and limited this individual’s life? informal measures to describe the nature and severity
As mentioned earlier in this chapter, ongoing struggle of an adult’s stuttering disorder. Assessment procedures
to produce speech often creates many layers of negative must include tasks to measure the frequency, dura-
emotions. These may be quite pervasive in the adoles- tion, and types of disfluencies present in monologue,
cent or adult who stutters but difficult to observe and dialogue, and reading contexts, along with qualitative
measure. Although pretreatment measures of stuttering measurement of associated behaviors and calculation
severity may ultimately be the most reliable predictor of speech rate. Results of these analyses can be used to
of treatment outcome (see Block, Onslow, Packman, & complete a protocol such as the SSI-4, which will pro-
Dacakis, 2006), the development of learned helplessness vide diagnostic information about stuttering severity.
and confirmed self-perception as a poor communicator Of equal importance, however, will be the inclusion
can be serious impediments to successful fluency inter- of measures that provide information about other
vention and must be explored during an initial evalua- aspects of the stuttering disorder. The Perceptions of
tion. Sometimes, experienced stutterers may negotiate Stuttering Inventory (PSI; Woolf, 1967), for example,
anticipated disfluencies so skillfully that core behaviors may help the clinician understand the extent of strug-
will not be observed at all and assessment will need to gle perceived by the client who stutters, the client’s
tap into hidden emotions, attitudes, and fears in order anticipation of failure during attempts to speak, and
to uncover any evidence of a stuttering disorder. the extent to which he or she avoids speaking situa-
Interview questions for the adult who stutters will be tions. The Modified Scale of Communication Attitude
similar to those presented for younger populations, but (S-24) developed by Andrews and Cutler (1974) and
rather than focusing primarily on the “tip of the iceberg” the Communication Attitude Test for Adults (BigCAT)
(that is, observable speech disfluencies), they will place by Brutten and Vanryckeghem (2003) both reflect the
equal emphasis on aspects of the disorder that lie beneath client’s perceptions of him- or herself as a communi-
the surface. Following are suggested areas of inquiry: cator, and his or her attitude toward communication in
general. Locus of control measures, such as the Locus
● When did your stuttering start? How has it of Control of Behavior (LOC-B) developed by Craig
changed since then? et al. (1984) or the Speech Locus of Control Scale
● How does your stuttering feel, physically and (Sp-LOC) by McDonough and Quesal (1988), provide
emotionally? specific information about whether the client views life
● How do different situations and/or listeners af- circumstances as the result of external forces or inter-
fect your stuttering? nal control. Understanding the way an individual views
● Do you have specific “tricks” that you use to get events or approaches change, can be essential in design-
out of difficult blocks? ing and planning appropriate stuttering intervention.
● Have you had prior therapy? Describe these Numerous more recent protocols explore stuttering dis-
treatment experiences. Are there any specific orders from a more holistic perspective. These protocols
strategies or techniques that have been helpful? provide measures of core behaviors as well as information
● Do you avoid speaking or social situations? Has about the ways in which an individual may be reacting
your stuttering contributed to certain decisions to his or her stuttering and the overall impact of stut-
that you have made in your life (e.g., relation- tering on the individual’s life. Examples of such mea-
ships, career choices)? sures include Yaruss and Quesal’s Overall Assessment
● What do you aim to achieve in therapy? What of the Speaker’s Experience of Stuttering (OASES) for
is your primary goal? Teenagers and Adults (2010) and the Wright and Ayre
● Why have you decided to pursue treatment now? Stuttering Self-Rating Profile (WASSP; 2000).
 A S S E S S M E NT OF F L U E NC Y D IS OR D E R S 371

Stimulability testing for adolescents and adults techniques drawn from different treatment approaches
can provide insight into the client’s level of behav- can help guide the clinician in planning intervention
ioral self-awareness, that is, the client’s ability to iden- that will be most appropriate for the individual client to
tify moments of disfluency or anticipated moments of most likely succeed.
disfluency. Poor performance may suggest the need to
heighten the client’s attention to the physical sensa-
tions associated with stuttering in order to eventually FORMAL AND INFORMAL
help him or her control disfluencies through stuttering ASSESSMENT MEASURES
modification techniques. Reluctance or refusal to par-
ticipate in such tasks may indicate the need to focus on
FOR STUTTERING DISORDERS
desensitization in therapy or to consider initiating treat- Informal and formal assessment measures for stuttering
ment with a fluency-shaping approach. In general, trial disorders are described in Tables 13-13 and 13-14.

Table 13-14. Measures and Scales for Adolescents and Adults Who Stutter.

MEASURE/SCALE Author/Publisher Age Range Behaviors Assessed

Adult Behavior Assessment Battery (BAB): Brutten & Adults Anxiety ratings for different situations; cop-
combination of Behavior Checklist for Vanryckeghem ing responses for dealing with disfluencies;
Adults, Adult Communication Attitude Test (2003)* attitudes toward communication
(BigCAT), and Speech Situation Checklist
for Adults
Behavior Assessment Battery (BAB): Vanryckeghem & 6–15 Anxiety ratings for different situations; cop-
combination of Behavior Checklist, Brutten (2007a); ing responses for dealing with disfluencies;
Communication Attitude Test, and Speech available through attitudes toward communication
Situation Checklist Plural Publishing
Behavior Checklist for Adults (BCL) Brutten & Adults Coping responses
Vanryckeghem
(2003)*
Brutten & Adults Speech-related attitudes
Communication Attitude Test for Adults
(BigCAT) Vanryckeghem 13
(2003)*

FLUENCY DISORDERS
Crowe’s Protocols Crowe, DiLollo, & Children, Affective, behavioral, and cognitive
Crowe (2000) adolescents, aspects of stuttering; stuttering severity;
adults stimulability
Locus of Control and Behavior (LOC-B) Craig, Franklin, & Older children, Extent to which a person perceives
Andrews (1984) adolescents, outcome of events to be under internal
and adults or external locus of control
Modified Scale of Communication Attitudes Andrews & Adolescents Feelings, attitudes, and self-esteem
(S-24) Cutler (1974) and adults
Overall Assessment of the Speaker’s Yaruss, Quesal, & Adolescents Perception of stuttering; reactions to
Experience of Stuttering–Teenager Coleman (2010) (12–17) stuttering; impact of stuttering on communi-
(OASES-T) cation and quality of life
Overall Assessment of the Speaker’s Yaruss & Quesal Adults Perception of stuttering; reactions to stut-
Experience of Stuttering–Adult (OASES-A) (2010) tering; impact of stuttering on communica-
tion and quality of life
(Continues)
372 CHAPTER 13

Table 13-14. (Continued).

MEASURE/SCALE Author/Publisher Age Range Behaviors Assessed

Perceptions of Stuttering Inventory Woolf (1967) Adolescents Speaker’s perception of the struggle,
and adults avoidance, and expectancy of stuttering
Rathus Assertiveness Schedule (RAS) Rathus (1973) Adults Assertiveness
Rosenberg Self-Esteem Scale (RSE) Rosenberg (1979) Grade 5 and up Self-esteem
The Speech Situation Checklists Brutten & Adults Emotional reactions to disfluencies
for Adults (SSC-ER and SSC-SD) Vanryckeghem
(2003)*
Stuttering Problem Profile Silverman (1980) Adults Identifies behaviors to be modified in
therapy
Stuttering Severity Instrument–4 Riley (2009); pub- 2;10–adult Frequency and duration of disfluencies;
lished by Pro-Ed physical concomitants
Stuttering Severity Scale Lanyon (1967) Adults Severity of stuttering behaviors; attitudes
and feelings
Subjective Screening of Stuttering (SSS) Riley, Riley, & Magu- Adults Stuttering severity; locus of control;
ire (2004) avoidances
Unhelpful Thoughts and Beliefs St. Clare, Menzies, Adults Speech-related social anxiety
about Stuttering (UTBAS) Onslow, Packman,
Thompson, & Block
(2009)
Wright and Ayre Stuttering Self-Rating Wright & Ayre (2000) 18–adult (14–18 with Speaker’s perceptions of stuttering
Profile (WASSP) clinical judgment) behaviors; negative thoughts and feelings;
avoidances and “disadvantage” due to
stuttering
* Adult SSC, BCL, CAT, and BAB commercially published in Belgium and the Netherlands; not yet available in the United States.

DIFFERENTIAL DIAGNOSIS (4) excessive coarticulation and reduced speech intel-

ligibility, and (4) poor self-monitoring (St. Louis &
OF STUTTERING AND CLUTTERING
Myers, 1997). An important difference between the two
In this final section, we briefly consider the differen- disorders is that stuttering consists primarily of atypi-
tial diagnosis of stuttering and a closely related flu- cal forms of disfluency, such as prolongations or blocks,
ency disorder, cluttering. Detailed information related whereas cluttering involves typical disfluencies such as
to the assessment of cluttering is beyond the scope of interjections, revisions, or phrase repetitions that usu-
this work; however, numerous books, websites, and ally occur without visible struggle or tension (Guitar,
journal publications on this topic are listed at the end 2006, p. 445). According to Daly and Burnett (1999),
of this chapter. Cluttering is classified as a disorder of individuals with cluttering may present with diffi-
fluency but is distinct from stuttering based on certain culty in five communicative dimensions: (1) cognitive,
key features that include: (1) abnormal fluency that is (2) linguistic, (3) pragmatic, (4) speech, and (5) motor
not consistent with stuttering, (2) rapid and/or irregu- abilities. Several possible impairments in each dimen-
lar speech rate, (3) disorganized language formulation, sion are listed in Table 13-15.
 A S S E S S M E NT OF F L U E NC Y D IS OR D E R S 373

Table 13-15. Communicative Dimensions Affected in Cluttering Disorders.

COGNITION Language Pragmatics Speech Motor

• Poor self-monitoring • Difficulty organizing • Inappropriate turn-taking • Excessive repetitions • Prosody problems
• Impulsivity thoughts • Verbose or tangential of words and phrases • Poor penmanship
• Memory difficulties • Sentence fragments • Poor eye contact • Omission of sounds or • General clumsiness,
• Oral and written syllables poor coordination
• Poor attention span • Inappropriate introduc-
language difficulty tion or maintenance of • Syllable transpositions
• Difficulty listening and/ conversational topics
or following directions
Source: Based on data from Daly & Burnett (1999).

Table 13-16. Cluttering versus Stuttering.

Cluttering Stuttering
Onset Often not diagnosed until school years Onset typically between 2–5 years
Disfluencies Excessive normal disfluencies (between-word) Atypical disfluencies (primarily within-word)
Awareness/concern Frequently unaware of problem Highly aware, frustrated, and embarrassed
Articulation Slurred, imprecise No articulation difficulty
Reaction to pressure Improved performance under pressure or on demand Poorer performance under pressure
Language skills Disorganized discourse, word-finding difficulties, Language skills generally age-appropriate
grammatical errors
Written expression Disorganized, parallels verbal expression Normal writing skills
Attention More frequent diagnosis of attention deficit Attention deficits less frequent
Pragmatic skills Impatient listening, difficulty processing nonverbal No pragmatic deficits
cues, poor conversational skills
Associated behaviors Generally absent Generally present
13
Tension/struggle Generally absent Generally present

FLUENCY DISORDERS
Avoidance behaviors Generally absent Generally present
Source: Based on Daly & Burnett (1999) and Guitar (2006, pp. 451–452).

The Predictive Cluttering Inventory (PCI), originally

developed by Daly and Cantrell (2006) and recently
SUMMARY
revised (Van Zaalen et al., 2009), may be helpful for This chapter began with an allusion to Sheehan’s well-
identifying symptoms associated with cluttering; how- known comparison of observable stuttering symptoms
ever, it is not a very reliable or sensitive measure in its to the “tip of an iceberg.” We hope that the details
current form (Van Zaalen et al., 2009). In Table 13-16, provided in this chapter will help clinicians explore
we compare characteristics of stuttering and cluttering beneath this surface and feel comfortable measur-
to assist clinicians in this differential diagnosis. ing and interpreting not only core behaviors but also
374 CHAPTER 13

underlying perceptions, attitudes, and beliefs in the per- rate was measured as the number of syllables
son who stutters. This chapter also illustrated the need per minute (spm). The frequency of disfluencies
for broadening the diagnostic scope in order to consider in each context was measured as the percentage
how various environmental features may contribute of total syllables stuttered (%SS), with results as
to a stuttering disorder. Approaching the assessment follows:”
process from this more holistic perspective will enable
the clinician to appreciate the complex interactions Speaking Rate Frequency of
that ultimately determine the way a stuttering disor- CONTEXT (spm) Disfluencies (%SS)
der is manifested in a particular individual. Specific age Monologue 190 11
groups were considered individually, based on certain Dialogue 196 12.5
patterns in the way stuttering develops and evolves over
Reading 183 9
time, as well as important differences in the diagnostic
questions relevant for each age group. In line with this
general structure, we next present a case history and “Disfluencies generally occurred in clusters and
model report for each of the age groups discussed in consisted primarily of stutter-like disfluencies (SLDs),
order to demonstrate and apply some of the key con- which included sound repetitions (e.g., m-m-my name
cepts reviewed in this chapter. is M-M-Michael), prolongations (e.g., I like the sss-
summer), and tense blocks. Several non-SLDs were ob-
served (interjections, revisions); however, these did not
represent the majority of disfluencies. When results were
CASE HISTORY combined across speaking contexts, SLDs represented
AND MODEL REPORTS 83% of total disfluencies; non-SLDs represented only
Writing Rubric for Sample Reports 17% of total disfluencies. The average duration of the
three longest disfluencies was approximately 2.5 seconds.
The following guidelines may be useful in preparing the Frequent accessory behaviors were observed, including
Fluency section of a diagnostic report: finger tapping, head movements, and obvious facial
1. Describe the specific contexts in which speech tension.”
samples were obtained (e.g., play interaction 3. For formal measures, provide an introductory
with parent, play with pressure, monologue, dia- statement that includes the full test name,
logue, reading, etc.). abbreviated test name in parentheses, and a
2. Provide a summary of informal analyses that brief description. For example: “The Stuttering
includes: total number of syllables in sample; Instrument–4 (SSI-4) was completed based on
speech rate; total frequency of disfluencies (typi- speech sample results. This measure provides a
cally expressed as a percent of total syllables or severity rating based on quantification of core
words); frequencies or relative proportions of stuttering behaviors and accompanying physical
between-word and within-word disfluencies; symptoms.”
list of disfluency types observed with examples 4. Provide a summary of derived scores in a table
for each; average duration of longest disfluen- form followed by a paragraph that interprets
cies (number of reiterations and/or in seconds); and explains these results. For example: “Overall
occurrence of clusters; and presence or absence scores obtained on the SSI-4 fell between the
of accessory behaviors. For example, “Informal 61st and 77th percentile, which means that this
analyses were based on speech samples obtained child demonstrated greater disfluency than 61%
during monologue, dialogue, and reading, with to 77% of children his age. These results indicate
a total of 300 syllables in each sample. Speaking a moderate stuttering disorder.”
 A S S E S S M E NT OF F L U E NC Y D IS OR D E R S 375

5. To report results of scales measuring percep- mother’s description, disfluencies increased approxi-
tions, attitudes, or feelings, provide the scale mately 1 month following onset and now consist of fre-
name, authors, year of publication, and what quent repetitions of phrases, whole words, and sounds.
the scale purports to measure. In paragraph Eric’s mother has also noticed tension around his face
form, describe the client’s responses and how and mouth when he is struggling to produce certain
these compare to original findings reported by words. She is especially concerned because there is a
the author(s) for stuttering and nonstuttering history of stuttering in Eric’s father’s family.
individuals. For example: “The S-24 (Andrews
Selection of Assessment Procedures (Preschool)
& Cutler, 1974) was administered to assess the
client’s general attitude toward communication. Several types of interactions were planned and
The client’s total score was 18, which indicates recorded in order to obtain representative samples
distinctly negative reactions toward disfluen- of Eric’s speech: (1) play interaction with Eric and
cies and communication overall. This score his parents at the clinic, (2) play interaction with
corresponds to normative data obtained for Eric and the clinician, and (3) conversational inter-
stuttering adults (mean " 19.22) rather than action with Eric and his parent at home. An infor-
nonstuttering adults (9.14), suggesting that the mal analysis of all speech samples was completed in
client strongly identifies with perceptions and order to determine the overall frequency of disfluen-
attitudes that are typical of people who stutter.” cies and individual frequencies of SLDs versus ODs.
6. Describe stimulability testing and results. For Two measures were used in order to interpret speech
example: “Brief trials of pull-outs were at- sample results. The Stuttering Severity Instrument–4
tempted with the client following an explana- (SSI-4) was selected as an age-appropriate standard-
tion and demonstration; however, the client ized measure of stuttering severity and the Pindzola
had significant difficulty identifying discrete Protocol for Differentiating the Incipient Stutterer
moments of disfluency.” was selected in order to determine whether Eric’s
disfluencies were developmentally typical or not.
Core subtests of the Clinical Evaluation of Language
Case History (Preschool) Fundamentals–Preschool 2 (CELF-Preschool 2) were
Eric is a 3;2-year-old boy who began showing signs also administered to screen language skills and con-
of childhood stuttering several months ago when firm that disfluencies were not related to weaknesses 13
his family moved to a new apartment. Based on his in language processing.

FLUENCY DISORDERS
376 CHAPTER 13

SAMPLE REPORT (PRESCHOOL)

SPEECH-LANGUAGE EVALUATION
Name: Eric Taylor
Address: ____________________________________________________________________________________________
Date of Birth: 2/13/04
Date of Evaluation: 4/30/07

I. Background Information
Eric is a 3-year, 2-month-old child who was seen for a fluency evaluation due to parental concern regard-
ing stuttering. Eric was accompanied by his mother, Ms. Taylor, who served as a reliable informant. The
presenting problem, as described by Eric’s mother, was increasing disfluency over the past several months,
along with emerging frustration.
Eric was born via a full-term pregnancy and C-section delivery with no reported complications during
pregnancy or birth. Birth weight was 8 pounds, 10 ounces. Medical history includes asthma (since age 3)
and an allergic reaction to penicillin at 9 months. Eric currently takes Albuterol for asthma as needed.
Motor milestones were achieved at age expectancy, with sitting occurring at 4 months, crawling at 6 months,
standing at 8 months, and independent walking at 12 months. Eric began feeding himself at approximately
9 months, dressed independently between 1½ to 2 years, and was toilet trained at age 2. Early speech and
language development was grossly within normal limits, with single words emerging at around 18 months
and word combinations at 2 years.
Eric resides with his mother, Ms. Taylor, age 25, and his sister, Bridget, who is 2 years old. His father re-
sides elsewhere but sees Eric several times a week. English is the only language spoken at home and by
the child. Eric attends a local preschool program where he is reportedly doing well, both academically and
socially. He was described by his mother as a “shy” child who warms up slowly to people who are familiar to
him. Eric enjoys building, drawing, and coloring but also plays and interacts appropriately with neighbor-
hood friends and relatives.
II. Speech/Language History
Onset of stuttering was several months ago, coinciding with a move to a new apartment. Disfluencies
increased in frequency approximately 1 month following onset. As described by his mother, stuttering is
characterized by repetitions of phrases, words, and sounds and becomes noticeably worse when Eric is upset
or excited. Disfluencies occur throughout the day and are accompanied by visible tension around the face,
which have become somewhat more pronounced over the past several weeks. There is a family history of
stuttering (Eric’s father and paternal uncle received speech therapy for stuttering when they were children;
both still stutter). Eric has not received any prior speech-language services.
III. Tests Administered/Procedures
Oral-Peripheral Examination
Clinical Evaluation of Language Fundamentals–Preschool 2 (CELF-Preschool 2)
 A S S E S S M E NT OF F L U E NC Y D IS OR D E R S 377

SAMPLE REPORT (PRESCHOOL), continued

Goldman-Fristoe Test of Articulation

Speech Sample Analysis (plays with clinician, plays with parent, home sample)
Informal Fluency Analysis
Protocol for Differentiating the Incipient Stutterer
Stuttering Severity Instrument–4 (SSI-4)
IV. Clinical Observations
Eric presented as a playful, friendly child who was easily engaged in interactive play. He showed affect read-
ily, maintained appropriate eye contact, and was cooperative throughout assessment.
Hearing Mechanism
Complete audiological evaluation at this facility on 4/21/07 revealed hearing thresholds within normal
limits at all test frequencies (250–8000 Hz) for both ears. Immittance testing revealed normal middle ear
function bilaterally. Acoustic reflexes were elicited at expected levels.
Oral-Peripheral Speech Mechanism
Cursory inspection of the oral-peripheral mechanism revealed no gross structural deviations. Strength
and function of all oral and facial musculature were within normal limits for both speech and nonspeech
purposes.
Language
Language skills were assessed via screening subtests of the Clinical Evaluation of Language Fundamentals–
Preschool 2 (CELF-Preschool 2) with the following resulting scores:
CELF-Preschool 2
SUBTEST Standard Score
Sentence structure 13*
13
Word structure 13*

FLUENCY DISORDERS
Expressive vocabulary 11*
Core language score 114** (82nd percentile)
*Mean " 10; standard deviation ±3.
**Mean " 100; standard deviation ±15.

Standard scores for individual subtests all fell within the average to high-average range for Eric’s age level.
Eric’s core language score was 114, which falls at the 82nd percentile and indicates high-average overall
language ability.
Informal assessment of language (based on unstructured play and a picture description task) corroborated
formal test findings. Eric responded appropriately to questions and directions during play and expressed
himself in short but complete sentences with age-appropriate vocabulary and syntax.

(Continues)
378 CHAPTER 13

SAMPLE REPORT (PRESCHOOL), continued

SPEECH-LANGUAGE EVALUATION
Articulation
Assessment of articulation skills via the Goldman-Fristoe Test of Articulation revealed age-appropriate
speech sound production. Overall intelligibility was good at the single-word level, as well as in connected
speech, for both known and unknown contexts.
Voice
Vocal pitch, quality, and volume were appropriate for age and gender.
Rate/Fluency/Rhythm
Three spontaneous speech samples were obtained: one during a play interaction with the clinician, one during
a play interaction with the parent at the clinic, and one during a conversational interaction with the parent at
home. Results were analyzed individually but then combined due to consistency of findings across contexts.
Analysis of core stuttering behaviors was based on a total of 800 syllables and revealed the following:
Number of disfluencies per 100 syllables (% stuttered syllables) 19
Number of stutter-like disfluencies (within-word) per 100 syllables 15
Number of developmentally typical disfluencies per 100 syllables 4

Overall frequency of disfluencies was approximately 19% of total syllables, with the majority of disfluencies
occurring in clusters (multiple disfluencies per utterance). Disfluency types consisted primarily of within-
word disfluencies (also known as “stutter-like disfluencies”), which are generally considered atypical. These
included blocks, sound prolongations, sound repetitions, syllable repetitions, and monosyllabic word rep-
etitions. Some between-word disfluencies were observed (e.g., phrase repetitions, interjections, revisions);
however, the majority of disfluencies in the sample did not fall in this category.
Disfluency types and frequency of each type (expressed as a percentage of total syllables in the sample,
or %SS) were as follows:

Between-Word Disfluencies Within-Word Disfluencies

(more typical) (less typical)
Disfluency Type Frequency (%SS) Disfluency Type Frequency (%SS)
Phrase repetition 2 Single-syllable word repetition 1
Interjection 1 Syllable repetition 1
Revision 1 Sound repetition 3
Prolongation 4
Block 6
Total between-word: 4 Total within-word: 15
 A S S E S S M E NT OF F L U E NC Y D IS OR D E R S 379

SAMPLE REPORT (PRESCHOOL), continued

When disfluencies involved repetition, the typical number of reiterations was 2-3; the average duration
of the 3 longest disfluencies in the sample was approximately 3 seconds. Several emerging secondary be-
haviors were observed, including occasional rise in pitch, audible vocal tension, visible tension around the
mouth and eyes, and frequent loss of eye contact during moments of disfluency. Two standardized stutter-
ing measures were completed based on Eric’s sample and are described below.
The Protocol for Differentiating the Incipient Stutterer (Pindzola & White, 1986) is designed to identify
preschool children whose stuttering is likely to persist based on specific disfluency parameters. Total score is
based on measurement of auditory behaviors (frequency, type, and duration of disfluencies) as well as visual
evidence of accessory behaviors. Eric’s results were as follows:

Protocol for Differentiating the Incipient Stutterer

Total score 35
Interpretation Probably atypical*
*1–20 " probably typical; 20–42 " probably atypical.

The Stuttering Severity Instrument–4 (SSI-4) provides a severity rating based on quantification of a child’s
core stuttering behaviors (frequency, duration) and physical concomitants. Results for Eric were as follows:
SSI-4
INDIVIDUAL SCORES Sample Data SSI-4 Score
Frequency (calculated for nonreader) 15% total syllables (non-SLDs excluded) 16
Duration 3 seconds 10
Physical concomitants Visible tension (eye, face), pitch rise, poor eye contact 5
Total overall score 16 ! 10 ! 5 31
Percentile 89th–95th 13
Severity Severe

FLUENCY DISORDERS
Combined results of the Pindzola Protocol and SSI-4 indicate a severe stuttering disorder that is most
likely atypical—that is, more consistent with stuttering than with typical developmental disfluency. Speech
and language therapy is strongly recommended to help Eric learn to use slow/relaxed forms of speech and
to help parents implement communication styles that will support and enhance fluency at home. Eric was
able to imitate several trials of slow and easy speech at the single-word level but will need further practice
with longer and more spontaneous speech contexts.
V. Clinical Impressions
Eric Taylor, a 3-year, 2-month-old male, was seen for a speech and language evaluation to assess parental
concerns regarding stuttering. Findings revealed a severe stuttering disorder marked by excessive disfluen-
cies that were primarily atypical, and that were frequently accompanied by visible tension around the face

(Continues)
380 CHAPTER 13

SAMPLE REPORT (PRESCHOOL), continued

SPEECH-LANGUAGE EVALUATION
and eyes, an audible rise in pitch, and loss of eye contact, all of which indicate emerging awareness, tension,
and struggle. Language skills, articulation, and vocal function were age appropriate.
VI. Recommendations
Parent was informed of findings and demonstrated awareness of the following:
1. Indirect strategies for fluency management were discussed with parent with specific recommendations
including: parental use of slower speech rate; regular one-on-one time with Eric during which specific
methods for reinforcing fluency can be implemented; avoiding negative reactions, such as anxiety, fear,
or sadness in response to Eric’s disfluencies; use of consistent turn-taking during conversations, with
care to avoid “talking over” each other.
2. Direct fluency treatment: teach Eric to use slow, easy speaking patterns, implement fluency-
supporting patterns of conversation.
3. Home therapy program to reinforce treatment goals: specific exercises to practice treatment targets,
inclusion of siblings.

______________________________ Date_______________
(Name of clinician or clinical supervisor and credentials)
Speech Language Pathologist
 A S S E S S M E NT OF F L U E NC Y D IS OR D E R S 381

Case History (School-Age) reading. For the monologue sample, Emily summarized
the plot of a movie she had recently seen. The reading
Emily is a 7-year-old child who briefly stuttered at task was based on a simple story book at the first-grade
age 2 and is now showing reoccurrence of stuttering level. An informal analysis of each speech sample was
symptoms. Based on her mother’s description, disfluen- completed to determine the overall frequency of dis-
cies fluctuate in frequency and severity but are consis- fluencies and relative frequencies of SLDs versus ODs.
tently observed on most days. Disfluencies reportedly The Stuttering Severity Instrument–4 (SSI-4) was
consist of word and syllable repetitions with no obvious selected as an age-appropriate standardized measure of
signs of tension or struggle. Emily is an outgoing and stuttering severity. The A-19 (Andre & Guitar, 2006)
popular child and does not seem to avoid speaking situ- was administered in order to assess Emily’s underly-
ations; however, her mother was concerned that Emily ing attitudes about her speech and about communica-
may be privately self-conscious or ashamed about her tion. The Expressive and Receptive One-Word Picture
stuttering and that this might eventually limit her either Vocabulary Tests were selected as age-appropriate stan-
academically and/or socially. dardized measures of vocabulary skills in order to com-
Selection of Assessment Procedures pare receptive and expressive word knowledge and rule
(School-Age) out possible word-retrieval difficulties.
Three tasks were selected in order to obtain representa-
tive samples of Emily’s speech: monologue, dialogue, and

13

FLUENCY DISORDERS
382 CHAPTER 13

SAMPLE REPORT (SCHOOL-AGE)

SPEECH-LANGUAGE EVALUATION
Name: Emily Ross
Address: ____________________________________________________________________________________________
Date of Birth: 2/13/01
Date of Evaluation: 4/30/08

I. Reason for Referral

Mrs. Ross requested a speech-language evaluation for her 7-year-old daughter, Emily, due to concerns
about fluency. Emily was previously evaluated for stuttering at approximately age 2. At that time, stuttering
was intermittent with accompanying behaviors (hitting mouth with hand) occurring for a short period of
time. Direct therapy was not recommended; however, indirect management strategies were implemented at
home and disfluency eventually resolved.
Recent reemergence of stuttering symptoms was noted just after the summer and has been consistently
observed since then, both at home and school. Disfluency appears to fluctuate in frequency and severity
without any identifiable triggers. As described by Mrs. Ross, disfluencies consist of word and syllable rep-
etitions with no signs of visible tension or struggle. Emily seems to be aware of the problem but does not
show any specific fears or anxiety related to speaking. Family history is significant for several relatives with
stuttering, some with persisting severe disfluency into adulthood.
II. Background Information
Emily is the third of four children born to John and Pamela Ross. Pregnancy, birth, and medical history
were uncomplicated; developmental milestones were achieved at age expectancy.
Early language and academic skills were described as above average. Emily currently attends Public School 23,
where she is in a regular education second-grade class. She is described as a very verbal child and highly
motivated student. There are no academic concerns. Emily speaks English as her primary language.
III. Tests Administered/Procedures
Oral-Peripheral Examination Articulation
Receptive One-Word Picture Vocabulary Test (ROWPVT)
Expressive One-Word Picture Vocabulary Test (EOWPVT)
Informal Language Analysis
Speech Sample Analysis (conversation, monologue, and reading)
Stuttering Severity Instrument–4 (SSI-4)
IV. Clinical Observations

Hearing Mechanism
Emily reportedly passed a recent hearing screening administered at school. Formal results were unavailable
at the time of this evaluation.
 A S S E S S M E NT OF F L U E NC Y D IS OR D E R S 383

SAMPLE REPORT (SCHOOL-AGE), continued

Oral-Peripheral Mechanism and Articulation

Cursory inspection of the oral-peripheral mechanism revealed no gross structural deviations. Strength and
function of oral musculature were normal. No speech sound production errors were reported or observed
throughout assessment.
Language
Formal Analysis
The Receptive One-Word Picture Vocabulary Test (ROWPVT) and Expressive One-Word Picture
Vocabulary Test (EOWPVT) were administered to screen basic vocabulary skills and compare receptive
and expressive word knowledge. The child is required to either point to the picture that corresponds to a
given word or provide labels for individual pictures, or groups of pictures. Emily’s results were as follows:
ROWPVT/EOWPVT
TEST Standard Score Percentile Rank
Receptive One-Word Picture Vocabulary Test 103* 58th
Expressive One-Word Picture Vocabulary Test 100* 50th
*Mean " 100; standard deviation ±15.

Emily’s standard scores of 103 and 100 for the receptive and expressive vocabulary measures, respectively,
both fell within the average range for age level, indicating that her word knowledge and word-retrieval
abilities are both age appropriate.
Informal Analysis
Language skills were informally assessed in discourse-level speech via question/answer exchange and a
story retell task. Results were consistent with the vocabulary scores described above. Emily used complete
sentences that were grammatically correct and included detailed elaboration. Word specificity and range
of vocabulary appeared generally appropriate for Emily’s age level. During the story retell task, Emily se- 13
quenced events accurately and provided a coherent story with much description. Eye contact, turn-taking,

FLUENCY DISORDERS
and other social conventions during conversation were all appropriate.
Fluency
Core Behaviors
Speech samples were obtained in several contexts, including conversation, monologue, and reading.
The reading sample was used for informal analysis but was excluded from formal analyses because data
are not included for children reading below a third-grade level. Overall frequency of disfluency during
speaking tasks was 9.3% of total syllables in conversation and 8.8% of total syllables during extended
speaking (monologue). Disfluencies consisted of word (“and-and-and”) and part-word (“pe-pe-pe-
people”) repetitions, usually with 2–3 reiterations. The longest duration of disfluencies was between 1.0

(Continues)
384 CHAPTER 13

SAMPLE REPORT (SCHOOL-AGE), continued

SPEECH-LANGUAGE EVALUATION
and 1.5 seconds. No obvious concomitant behaviors, such as unusual sounds, facial tension, or head/body
movements, were observed at moments of disfluency. Speech rate was generally average with occasional
portions of more rapid speech, usually occurring when Emily was relating a lot of detail about a particular
subject or event. Intonation and rhythm were normal during speech and reading tasks. Emily often self-
corrected decoding errors during the reading task; however, these were all corrections of miscues rather
than speech disfluencies. Overall calculations of stuttering behaviors were analyzed using the Stuttering
Severity Instrument–4 (SSI-4), with the following results:
SSI-4
MEASURE Task Score Percentile Rank Severity
Frequency of disfluency 14
Duration of stuttering events 6
Physical concomitants 0
Total Overall Score 20 24th–40th Mild-moderate

Combined scores yield a total task score of 20, which places Emily in the 24th to 40th percentile range for
her age level. This corresponds to a severity rating of mild bordering on moderate stuttering.
Attitudes and Feelings
Emily’s responses to questions about her speech, suggested awareness of disfluencies and some sensitivity
about her stuttering. She referred to her stuttering as “double talk” and stated that she is often advised by
others to talk slowly, but that does not seem to help her. She does not avoid speaking situations and openly
discussed her stuttering during this evaluation. Emily’s attitudes about her speech were further examined
via the A-19 Scale for Children Who Stutter, a written scale that requires written yes/no responses to 19
statements about communication. Emily’s total score was 4, which is quite low and is more consistent with
the mean obtained for nonstuttering children (8.17) than for stuttering children (9.07). Overall, Emily
appears to be somewhat self-conscious about her stuttering but has a healthy general attitude toward com-
munication and is not reacting to disfluencies in any significant way at this point.
A brief telephone conference with Emily’s classroom teacher, Ms. Thomas, on 5/2/10 corroborated the
A-19 findings described above. Ms. Thomas reported that Emily participates frequently in class discus-
sions, volunteers to read aloud, and is popular among her peers. Overall, Emily is perceived by her teacher
as a confident student who communicates freely despite occasional disfluency. No teasing or bullying was
reported.
Stimulability
Stimulability was assessed via several trials of fluency-shaping techniques, including easy onsets (on single
words), continuous phonation on short phrases (e.g., How are you?), and rate control during a long sentence.
 A S S E S S M E NT OF F L U E NC Y D IS OR D E R S 385

SAMPLE REPORT (SCHOOL-AGE), continued

Emily responded well to all methods following brief explanation and demonstration. Several trials of pull-
outs were attempted; however, these seemed more difficult for Emily because her disfluencies tended to
have a short duration and her speech rate was often too rapid for her to identify and modify moments of
disfluency effectively.
V. Summary and Recommendations
Emily is a 7-year-old daughter with a borderline mild-moderate fluency disorder. Her disfluencies gener-
ally consist of phrase, word, or part-word repetitions that occur fairly frequently but are not accompanied
by any visible tension or other obvious physical behaviors. Emily is aware of her stuttering in a general
sense and is somewhat self-conscious but has a healthy overall attitude toward communication. She is fre-
quently told by others to speak more slowly but does not find this helpful, and has no other effective means
of managing disfluencies. Indirect and direct speech therapy is recommended, focusing on implementing
methods to promote fluency at home and school, educating Emily and her family about stuttering, prac-
ticing strategies for fluent speech, and managing moments of disfluency as they occur. It is important for
Emily to have an effective and reliable method of controlling her speech in order to avoid the development
of compensatory methods, negative habits, and speech-related anxiety.
Speech therapy is recommended to address the treatment goals described above. Ongoing discussion of
goals and progress with family members and teachers is also recommended in order to ensure that fluency
is being properly supported at home and in school. Finally, Emily may benefit from joining support groups
that have been formed for children who stutter in her community. Participation in support group activities
may help Emily become less self-conscious about her stuttering and help her benefit from the experiences
of other children with similar difficulties.

________________________________Date_______________
(Name of clinician or clinical supervisor and credentials)
13
Speech-Language Pathologist

FLUENCY DISORDERS
386 CHAPTER 13

Case History (Adult) Selection of Assessment Procedures (Adult)

Amanda is a 22-year-old college student referred for a Representative samples of Amanda’s speech were
fluency evaluation by her college counselor. She is cur- obtained in three contexts: monologue, dialogue, and
rently majoring in theatre and aspires to become a the- reading. A timed monologue was also recorded to
atre director. Amanda began stuttering when she was 5 measure the effect of imposed pressure on disfluencies.
and has stuttered fairly consistently since then. She was Informal fluency analyses were performed on the three
evaluated previously but has never received interven- samples to determine speaking rate, disfluencies per
tion. Her stuttering is characterized by several types of minute, disfluency types, and disfluency durations. The
disfluencies (repetitions, prolongations, interjections), in Locus of Control of Behavior Scale was selected as an
addition to certain accessory behaviors and avoidances. age-appropriate informal measure of attitudes and con-
Amanda is comfortable speaking with most people and fidence level related to daily communication situations.
is not ashamed of her stuttering, but is anxious about
how stuttering may affect her future career.
 A S S E S S M E NT OF F L U E NC Y D IS OR D E R S 387

S A M P L E R E P O R T ( A D U LT )

SPEECH- LANGUAGE EVALUATION

Client: Amanda Rope
D.O.E: 1/11/2010
Address: ____________________________________________________________________________________________
Phone Number(s): ____________________________________________________________________________________
D.O.B: 1/11/1988
Diagnosis: Stuttering

I. Reason for Referral

Amanda Rope, a 22-year-old monolingual female, was seen at the clinic for an evaluation on January 11,
2010. She was referred for an evaluation by her college counselor to improve her fluency. Amanda disclosed
that she “wants to get some way to control” her stuttering. Amanda served as a reliable informant during
the evaluation.
II. Tests Administered/Procedures
Interview
Oral-Peripheral Mechanism Examination
Audiological Screening
Locus of Control of Behavior Scale
Informal Fluency Assessment
Stimulability Assessment
III. Background Information

Medical/Health History
Amanda reported during the interview that she has an unremarkable medical history. No known allergies,
13
illnesses, or hospitalizations were reported.

FLUENCY DISORDERS
Family/Social History
Amanda was born in Nigeria and immigrated to the United States with her family in 2000. She currently
resides in Bronx, New York, with her mother, brother, and two sisters. Amanda indicated that she feels
comfortable speaking with her family and is not embarrassed when she stutters, but is often shy and quiet
when meeting new people. She enjoys singing in the church choir with her friends, watching television,
writing, and reading novels.
Educational/Occupational History
Amanda attended high school in the United States and is currently in her fifth year at the clinic. She is
pursuing a bachelor’s degree with a major in theatre. She indicated that she is interested in directing theatre
productions.

(Continues)
388 CHAPTER 13

S A M P L E R E P O R T ( A D U LT ) , c o n t i n u e d

SPEECH-LANGUAGE EVALUATION
Fluency History
Amanda reported that she does not hide her stuttering and has learned to “control” emotions related to her
stuttering via specific techniques (e.g., controlling fears, relaxing in uncomfortable situations).
Amanda is motivated to improve her speech and indicated a desire to learn techniques for speaking fluently.
She is anxious when producing new and long words and experiences the most difficulty at school, where
she feels that her stuttering may be hindering her class work. She is also concerned that her disfluency may
interfere with her ability to communicate effectively in her future role as a theatre director.
Amanda indicated that she exhibits secondary characteristics such as shaking her head and averting eye
contact. During moments of stuttering, Amanda controls her speech by switching words.
Amanda reported a history of stuttering in her family. Amanda’s maternal uncle stutters, but she is not in
close contact with him, as he lives in Georgia. Amanda stated that she first demonstrated stuttering behav-
iors at approximately age 5.
Therapeutic History
Amanda reported that she has no previous history of speech or language therapy. A diagnostic evalu-
ation was conducted at the clinic in September 2006. Therapy was recommended; however, Amanda
did not pursue services at that time. Information obtained from the present evaluation corroborated previ-
ous assessment findings.
IV. Clinical Observations
Amanda presented as a pleasant young woman who was motivated and engaged in all required tasks during
the evaluation. She reported that improving her speech would maximize her opportunities in school and
help ensure future employment.
Oral-Peripheral Mechanism Examination
An oral-peripheral examination was conducted to assess structural and functional integrity of the speech
mechanism. Normal facial tone and symmetry were observed. Labial strength was observed to be within
normal limits. Velopharyngeal movement upon phonation of /a/ was normal. Lingual mobility for lat-
eralization, depression, and elevation appeared to be adequate for speech production. A diadochokinetic
syllable task was administered to assess rapid movements of the speech musculature. Amanda was able to
successfully produce the syllables /p^/, /t^/, and /k^/.
Audiological Screening
Amanda passed a hearing screening in which pure tones were presented bilaterally at 25 dBHL at the fre-
quencies of 500, 1000, 2000, and 4000 Hz, suggesting hearing within normal limits.
Articulation/Phonological Skills
Articulation skills were informally observed throughout the evaluation. Observation revealed no articula-
tion errors and overall intelligibility was judged to be good in both known and unknown contexts.
 A S S E S S M E NT OF F L U E NC Y D IS OR D E R S 389

S A M P L E R E P O R T ( A D U LT ) , c o n t i n u e d

Language Skills
Language was informally assessed throughout the evaluation. Assessment revealed age-appropriate lan-
guage skills. Cluttering was not suspected due to appropriate organization of expressive language skills and
overall ability to communicate effectively.
Voice and Vocal Parameters
Amanda’s vocal quality, pitch, resonance, and intensity were assessed through conversation and judged to
be within normal limits.
Fluency
Informal Assessment
Fluency skills were informally assessed to measure types of disfluencies, duration of disfluency, and speaking rate
in a variety of linguistic contexts within the clinical setting, including oral reading, monologue, and dialogue.
Reading
Amanda read a 22-sentence passage (“Nicknames,” by Shipley & McAfee, 2005) and a 1-minute sample
was recorded. The average reading rate based on this sample was 119 words per minute (wpm). According
to Shapiro (1999), the normal rate for oral reading in adults is 148–190 wpm. These results indicated that
Amanda had a reduced speech rate for oral reading. She exhibited a total number of 21 disfluencies per
minute, including initial sound repetitions (e.g., “n-n-n-nicknames”), whole word repetitions (“nicknames,
nicknames”), phrase repetitions (“some are not, some are not”) interjections (e.g., “um”), and prolongations
(e.g., a---apple”). Average duration of disfluencies was between 0.5 and 1.0 seconds during oral reading.
Amanda exhibited some secondary characteristics, including head jerking on first syllable repetition.
Monologue
In a 1-minute monologue, Amanda spoke at an average rate of approximately 130  wpm. According to
Shapiro (1999), the normal speech rate for monologue is 114–173  wpm. Compared to the speech rate 13
in reading, Amanda spoke at an appropriate speech rate during monologue. She exhibited a total of
20 disfluencies, primarily initial sound repetitions and interjections. Duration of disfluencies was 0.5 sec-

FLUENCY DISORDERS
onds for monologue. A timed monologue was elicited to determine the effects of imposed time pressure on
Amanda’s fluency. Results of a 1-minute sample revealed no change in her fluency patterns.
Conversation
In conversation, Amanda spoke at an average rate of approximately 93 wpm. The average rate for conver-
sational speech in adults is 115–165 wpm (Andrews & Ingham, 1971). Therefore, Amanda’s speech rate in
conversation falls slightly below average limits. Based on the clinician’s perception, Amanda’s speech rate
during conversation was judged to be adequate for her age. During a 1-minute speech sample, Amanda
exhibited a total of 23 disfluencies, including a combination of sound, whole-word and phrase repetitions,
interjections (e.g., “umm”), and prolongations (e.g., “aaaand”). The duration of Amanda’s disfluencies was
between 0.5 and 1.0 seconds for conversation. During this task, Amanda exhibited some secondary char-
acteristics, such as averting eye contact.
(Continues)
390 CHAPTER 13

S A M P L E R E P O R T ( A D U LT ) , c o n t i n u e d

SPEECH-LANGUAGE EVALUATION
In summary, the duration of Amanda’s disfluencies was between 0.5 and 1.0  seconds for oral reading,
monologue, and conversation. Amanda’s predominant core behaviors from most to least frequent were
repetitions (whole-word, phrase, and initial-sound repetitions), interjections, and sound prolongations.
Accessory speech behaviors such as head jerks and decreased eye contact were exhibited throughout oral
reading and monologue. Taped results of the informal assessment indicated that Amanda presents with a
mild-moderate stuttering disorder. This is due to the types of disfluencies and secondary characteristics that
she presents with, as well as the impact that stuttering has had on her life, both socially and academically
(see a summary of informal results below).
Summary of Informal Results
Rate of Disfluencies
CONTEXT Speech (wpm) per minute Duration Types of Disfluencies
Oral Reading 119 21 0.5–1.0 Repetitions, interjections, prolongations
Monologue 130 20 0.5 Repetitions, interjections
Conversation 93 23 0.5–1.0 Repetitions, interjections, prolongations

Attitudes and Feelings Associated with Stuttering

The attitudes and emotions component of the evaluation assessed how Amanda feels about her stuttering
in terms of self-esteem, locus of control, and assertiveness. The Locus of Control of Behavior Scale was
administered and it assessed Amanda’s self-confidence and attitudes in daily communication situations.
The test is comprised of 17 statements associated with speech-related behaviors and required Amanda to
rate situations from 0 (strongly disagree) to 5 (strongly agree). Amanda did not present with confirmed at-
titudinal perception. For instance, she revealed that her stuttering “will not dominate” her life. In addition,
she indicated that she is able to “anticipate difficulties and take action to avoid them.”
Stimulability Testing
A trial of stuttering intervention was presented during the session. The tasks involved using various fluency-
shaping strategies (easy onset, light articulatory contacts, and continuous phonation techniques). Prior to
the presentation of stimulus items, Amanda practiced each strategy while reading from a list of phrases and
sentences. Amanda did not have practice implementing strategies during moments of stuttering. Amanda
was stimulable for all the techniques; however, she was most comfortable applying easy onset.
V. Clinical Impressions
Amanda Rope, a 22-year-old monolingual female, presented with a mild-moderate stuttering disorder.
Predominant core behaviors were repetitions (whole-word, phrase, and initial-sound repetitions), interjec-
tions, and sound prolongations. Duration of disfluencies was between 0.5 and 1.0 seconds for monologue,
dialogue, and conversation. Physical accessory behaviors included loss of eye contact and head jerks dur-
ing moments of disfluency. As evidenced by the Locus of Control of Behavior Scale, Amanda did not
present with any confirmed attitudinal perceptions regarding her stuttering. Prognosis for improvement
 A S S E S S M E NT OF F L U E NC Y D IS OR D E R S 391

S A M P L E R E P O R T ( A D U LT ) , c o n t i n u e d

is good, due to the client’s motivation, awareness of disfluencies, positive perception of speaking abilities,
and stimulability for using fluency-shaping strategies (e.g., easy vocal onset and continuous phonation)
when producing words and phrases.
VI. Recommendations
Individual therapy is recommended once a week in a structured therapeutic setting to address the following
goals:
1. Counseling to address fluency issues and goals related to future activities/plans: Amanda’s intervention
should emphasize stuttering education, self-awareness of disfluent behaviors, and desensitization.
2. Long-Term Goal: Amanda will reduce anxiety and modify core behaviors and secondary characteris-
tics associated with stuttering.
Short-Term Goals
a. Amanda will identify primary and secondary characteristics of her stuttering (e.g., head jerking,
word switching, poor eye contact) during a 1-minute conversation with 80% accuracy.
b. Amanda will express her feelings/attitudes toward her stuttering in relation to family, social, and
school settings on 6–7 days of the week.
c. Amanda will perform desensitization activities (aimed at increasing awareness of stuttering and
reducing associated anxiety) on 4–5 trials.
3. Long-Term Goal: Amanda will produce fluent speech using easy vocal onset and continuous phona-
tion strategies.
Short-Term Goals
a. Amanda will produce easy vocal onset in words, phrases, and sentences with 80% accuracy.
b. Amanda will produce words, phrases, and sentences using continuous phonation with 80%
accuracy.

13
________________________________Date_______________

FLUENCY DISORDERS
(Name of clinician or clinical supervisor and credentials)
Speech-Language Pathologist
392 CHAPTER 13

revealed mild stuttering characterized by a relatively

NOVEL CASE HISTORIES low frequency of disfluencies, brief duration of disflu-
FOR PRACTICE encies, and no evidence of tension or struggle. Overall,
Next we present concluding paragraphs from two results were more consistent with developmentally
diagnostic reports. The first evaluation was conducted typical disfluency rather than beginning stuttering.
with Michael, a 2-year, 5-month-old child who began Language skills, articulation, and vocal function were
showing questionable signs of childhood stuttering all age appropriate.
13 months prior to assessment. The second evaluation Case 2: Julie Russo, a 31-year-old female, was seen
was conducted with Julie, a 31-year-old female with a for a fluency evaluation to assess concerns relating to
long history of stuttering. After reading each paragraph, a long history of stuttering. Findings revealed a severe
select specific formal and informal procedures that could stuttering disorder marked by frequent, long blocks that
have led to the conclusions described. Explain how each occurred across speaking contexts and that were usually
procedure would have been implemented, how it would accompanied by significant facial tension, head move-
contribute to the diagnostic conclusion, and how spe- ment, and/or audible gasping. Assessment of Julie’s
cific findings from that procedure or analysis would be feelings related to her speech indicated significant
reported in the full text of the evaluation. negative reactions to her stuttering, strong identifica-
Case 1: Michael Davis, a 2-year, 5-month-old tion with perceptions and attitudes that are typical of
child, was seen for a speech and language evaluation to people who stutter, and a number of specific fears and
assess parental concerns regarding stuttering. Findings avoidance behaviors.

abnormalities in speech rate, language formulation, ar-

GLOSSARY
ticulation, and self-monitoring.
Accessory behaviors: behaviors that begin as an at- Core behaviors: involuntary discontinuities in the flow
tempt to push out of disfluencies but eventually be- of speech that represent the key features of stuttering
come learned patterns that accompany core stuttering (e.g., repetitions, prolongations, blocks).
behaviors.
Disfluency: speech that is not fluent (does not neces-
Avoidance behaviors: attempts to circumvent mo- sarily imply abnormality).
ments of disfluency.
Dysfluency: a lack of fluency that is deemed abnormal.
Between-word disfluencies: discontinuities interfering
with smooth transitioning between words in an utter- Escape behaviors: speaker’s attempt to terminate a
ance (phrase repetitions, interjections, running starts, block (e.g., by blinking, stamping feet, moving head).
revisions). Incipient stuttering: early signs of a stuttering disorder
Blocks: a form of disfluency in which both airflow and (vs. developmental disfluencies).
sound are stopped during the production of speech. Interjections: insertion of extraneous, meaningless
Broken words: a form of disfluency involving a tense, words or phrases into the flow of connected speech
silent pause in the middle of a vowel, followed by abrupt (e.g., “um,” “you know”); often called fillers.
reinitiation of voicing. Locus of control of behavior (LCB): the extent to which
Clusters: the occurrence of two or more disfluencies on the outcome of events is attributed to external circum-
the same word or utterance. stances versus internal factors.
Cluttering: a fluency disorder characterized by pri- Prolongations: a form of disfluency in which sound or
marily typical forms of disfluency, as well as possible airflow continues, but articulatory movement is stopped.
 A S S E S S M E NT OF F L U E NC Y D IS OR D E R S 393

Real-time analysis: disfluency analysis performed Spontaneous recovery: recovery from childhood stut-
while the speech sample is being obtained. tering without any formal intervention or treatment.
Repetition: a typical or atypical form of disfluency that Stutter-like disfluencies (SLDs): disfluencies associated
involves reiterations of a phrase, word, syllable, or sound. with more chronic forms of stuttering, sometimes re-
Revisions: a form of disfluency (or escape behavior) in ferred to as within-word disfluencies.
which phrases or sentences are reformulated, often to Tremors: small, rapid muscle contractions.
avoid anticipated difficulty on a particular word or sound. Within-word disfluencies: discontinuities that interfere
Running starts: a form of disfluency (or escape behav- with smooth transitioning between sounds or syllables
ior) in which the speaker returns once or several times within a word (sound repetitions, syllable repetitions,
to the beginning of a thought or sentence in order to prolongations, blocks, broken words).
regain fluency.

Andrews, G., & Cutler, J. (1974). The relation between

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American Institute for Stuttering Woburn: MA: Butterworth Heinemann.
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FRIENDS and Treatment. Needham Heights, MA: Allyn & Bacon.
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http://www.stutterisa.org
Curlee, R. F., & Siegel, G. (1997). Nature and Treat-
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National Stuttering Association Guitar, B. (2006). Stuttering: An Integrated Approach
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Stuttering Foundation
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A Journal of Clinical Practice Parry, W. (2006). The Second Edition—Understanding
Contemporary Issues in Communication Science and Controlling Stuttering. A Comprehensive New Ap-
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Journal of Communication Disorders Ramig, P., & Dodge, D. (2005). Child and Adolescent
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Journal of Fluency Disorders York: Delmar/Cengage Learning.
Journal of Speech, Language, and Hearing Research Reardon, N. A., & Yaruss, J. S. (2004). The source for
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Perspectives on Fluency and Fluency Disorders (ASHA, Shapiro, D. A. (1999). Stuttering Intervention: A Collab-
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Seminars in Speech and Language Walton, P., & Wallace, M. (1998). Fun with Fluency.
The Journal of Stuttering Therapy, Advocacy, and Research Direct Therapy with The Young Child. Imaginart
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Recommended Books about Stuttering Zebrowski, P. M., & Kelly, E. M. (2002). Manual of
Bennett, E. (2006). Working with People Who Stutter. Stuttering Intervention—Clinical Competence Series.
A Lifespan Approach. New Jersey: Pearson. Clifton Park, NY: Delmar/Cengage Learning.

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