From the Desk of Ann Kummer
According to the NIH, approximately 3 million Americans stutter. Stuttering affects people of all ages, but it is most common in children, particularly boys, between the ages of 2 and 6, as they are developing language skills. NIH estimates that about 75 percent of children recover from stuttering, but for the remaining 25 percent, stuttering can be a lifelong communication disorder (https://www.nidcd.nih.gov/health/stuttering).
Stuttering can be very difficult to treat, especially if the speech-language pathologist (SLP) does not have sufficient training and/or experience in this area. Therefore, I’m so happy that Dr. Shelley Brundage is providing tips on treatment through this 20Q article.
Shelley B. Brundage, PhD, CCC, BCS-F, Fellow-ASHA, is professor and chair of the Department of Speech, Language, and Hearing Sciences at the George Washington University (GWU). She is a certified SLP and a board-certified specialist in fluency disorders. Her research addresses clinical questions that enhance the lives of persons who stutter, by improving procedures for assessment, treatment, and clinical education in stuttering. Recent work has merged her expertise in assessing student learning outcomes with her expertise in the development and use of virtual reality technologies; this work has led to a number of grants, publications, and awards for innovation. She teaches graduate courses on stuttering and research methods and is the recipient of numerous awards for teaching excellence and mentoring. She is the co-author of two books, the seventh edition of A Handbook on Stuttering and Writing Scientific Research in Communication Sciences and Disorders.
In this course, Dr. Brundage describes six core areas to assess in school-aged stuttering children: stuttering-related background information; speech, language, and temperament; speech fluency and stuttering; reactions of the speaker to stuttering; reactions to stuttering within the environment; and adverse impact of stuttering, along with examples of how to assess each area.
Now…read on, learn, and enjoy!
Ann W. Kummer, PhD, CCC-SLP, FASHA, 2017 ASHA Honors
Browse the complete collection of 20Q with Ann Kummer CEU articles at www.speechpathology.com/20Q
20Q: Consensus Guidelines for the Assessment of Stuttering Across the Lifespan
After this course, readers will be able to:
- List six core areas of a holistic stuttering assessment with school-aged children
- List 2-3 examples of how each area could be assessed
- Describe how stuttering is more than just disfluent speech
This 20Q article provides information gleaned from an article entitled Consensus Guidelines for the Assessments of Individuals Who Stutter Across the Lifespan (Brundage, et al. 2021). Although that article addressed stuttering assessment across the lifespan, this 20Q article will focus on school-aged children who stutter. There are some aspects of stuttering assessment that should occur regardless of the client’s age. Conversely, for certain age groups, particularly preschoolers, there are additional diagnostic considerations that must be considered; these diagnostic considerations are not addressed in detail here.
1. I don’t get many stutterers on my caseload and I’m not really confident when it comes to working with folks who stutter. Can you remind me again about what stuttering is?
That’s ok, you are not alone in lacking confidence in stuttering assessment and treatment (Eggers & Leahy, 2011; Kelly et al., 1997). There are also differences of opinion in the literature that can further complicate one’s understanding of what stuttering is and is not (e.g., Guitar, 2019; Manning & DiLollo, 2018; Yairi & Seery, 2023). Stuttering has affective, behavioral, and cognitive aspects, often called “the ABCs of stuttering” (see question 2). In addition, stuttering is variable, in that it manifests itself in different ways across speaking situations and listeners. The ABCs and the variable nature of stuttering can have negative impacts on communication, self-identity, and quality of life.
2. I thought stuttering was just about speech. What do you mean by the ABCs?
Stuttering involves more than just speech (Bloodstein, Bernstein Ratner, & Brundage, 2021). Speaking-related fear and anxiety are common affective reactions to the challenges that stutterers encounter when communicating. Examples might include being fearful about stuttering in certain speaking situations or being worried about listener reactions to stuttering. The behavioral aspects of stuttering include stuttered speech, muscular tension, and secondary behaviors. Cognitive aspects of stuttering include anticipation, avoidance, attitudes about one’s communication skills, and one’s reactions to one’s stuttering. Examples of cognitive aspects of stuttering include anticipating difficulty (such as stuttering or getting stuck and unable to communicate) in a given speaking situation and avoiding certain sounds, words, listeners, or speaking situations. The affective, behavioral, and cognitive aspects of stuttering influence each other in complex ways. For example, a CWS may anticipate that he will stutter when giving a presentation. This anticipation leads him to fear (affective) the presentation, which in turn might increase muscular tension and make stuttering more likely (behavioral). The stuttering leads to negative listener reactions, which in turn lead the stutterers to attempt to avoid presentations in the future (cognition). Over time, this cycle can lead to negative psychosocial impacts in the child’s life.
3. Hey wait. I thought we are supposed to use person-first language, such as “child who stutters,” so why did you say “stutterers” in question 2?
Both terms are ok to use, but it is important to understand how each of them came about. The term “child who stutters” is an example of person-first language, and this terminology stems from social models of disability. Social models view society’s reactions to disabilities as the source of the problem and use person-first language to make sure that disabled persons are not defined solely by their disability (Dunn & Andrews, 2015).
The use of identity-first language (e.g., “stutterer”) is advocated by the neurodiversity model, which views disabilities as part of a continuum of human variation, and not a “disability” or “problem” (Dunn & Andrews, 2015). The focus of the neurodiversity model is to accept, celebrate, and advocate for people who are neurodiverse. You can explore the neurodiversity model and how it has been applied to stuttering in the works of Constantino (2018) and Campbell and colleagues (2019).
4. How did you go about this study? I’m more familiar with quantitative research studies. How does one carry out qualitative studies and how do clinicians evaluate them?
Phenomenological studies aim to describe phenomena--in this case stuttering assessment--from the perspectives of people who have experienced the phenomenon (Creswell & Poth, 2018). These types of studies involve collecting information, identifying critical features in the information, and generating larger themes that capture the essence of the information obtained from the participants (Braun & Clarke, 2006; Hill et al., 1997). The process is iterative, in that the codes and themes are reviewed and re-reviewed until consensus is reached.
5. Seems like it’s important to know who the participants were, given the nature of the study. Who were they?
That’s correct. The participants were a group of 12 expert clinicians and researchers. They were invited to participate due to having a) published works on stuttering, b) expertise across the lifespan, c) differing philosophies regarding the nature of stuttering, and d) differing ideas regarding stuttering treatment.
6. What should I be focusing on during an assessment with a school-aged child? Typically I count words stuttered and go from there. Am I missing something?
If you are only counting stuttered words or syllables, then yes, you are missing important areas of stuttering that should be assessed. For stuttering children, the goals of the assessment include a) confirming the presence of stuttering, b) evaluating if the child is a candidate for treatment, and c) collecting data to guide treatment planning. The assessment process involves gathering information in six core areas, one of which involves stuttered speech.
7. OK, I can make my assessments more comprehensive and child-centered. What information should be obtained?
Let’s start with an overview of the six core areas that were identified as areas that should be assessed with school-aged stuttering kids. First, it’s important to obtain Stuttering-Related Background Information. The child’s Speech, Language, and Temperament should be assessed, either via screening test or full evaluation if warranted. The next area, Speech Fluency and Stuttering Behavior is perhaps the most familiar area for clinicians. It’s also important to assess the Speaker’s Reactions to Stuttering. We also need to gather information on the Reactions to Stuttering Within the Child’s Environment. Finally, we need to gauge the amount of Adverse Impact Associated with Stuttering. The goal is to gather information in each of these core areas during your assessment. A given client may have more to address in some areas and less in others. Assessing each core area allows you to get a holistic view of the client’s stuttering experience. There are many methods to gather information in each area; numerous examples are listed in the Appendices of the paper. The next few questions describe each core area in greater detail.
8. What types of case history questions should I be asking of parents, teachers, and the kids themselves?
I generally start with a broad, open-ended question that is borrowed from Solution Focused Brief Therapy, such as “what are your best hopes for our time together” (Nicholas, 2015) or an even more general question such as “what brings you in today?” and then move to more specific questions regarding stuttering onset, course, and how varies across situations and listeners. Asking about prior treatment, and the child’s and parents’ perceptions of it, is also a good idea. In terms of what exact questions to ask, our participants generated a list of potential that was over 7 pages long! There are numerous possible questions to ask; the answers should lead you to ideas of potential focus in treatment.
9. Why should speech, language, and temperament be routinely assessed with CWS?
Stuttering and language interact and influence each other in many ways (Brundage & Bernstein Ratner, 2022). Stuttering not only influences language production abilities, it also appears to influence language processing (Chang et al., 2009; Kreidler et al., 2017; Usler & Walsh, 2018). Numerous studies have documented subclinical language abilities in stuttering children (Ntourou et al., 2010; Shimada et al, 2018; Zaretsky et al., 2017), suggesting that evaluating linguistic skills in stuttering children is an important part of the assessment process, to insure understanding of how the child’s language skills influence stuttering, and vice versa. For example, stuttering increases as the length and complexity of linguistic targets increase (Bernstein Ratner & Sih, 1987), suggesting that speech fluency goals should occur, at least initially, at lower linguistic complexity levels.
The findings for articulation are more mixed, with some finding increased frequency of articulation disorders in stuttering children (Arndt & Healey, 2001) whereas others do not (Clark et al., 2013). Although SLPs do not treat temperament directly, a child’s temperament can influence treatment provision. Thus, obtaining information from parents may help the SLP plan more effective treatment sessions that accommodate the child’s temperament.
10. What advice can you give about collecting a valid speech sample with someone who stutters? What are best practices for counting stuttering moments?
Stuttering is notoriously variable (Constantino et al., 2016; Tichenor & Yaruss, 2021), varying in frequency and severity across time, speaking situations, and types of listeners. Therefore, in order to get an accurate measure of the nature and severity of the child’s stutter, it’s best to take multiple speech samples across different speaking situations and speakers. For example, samples could be taken when the child is talking to the SLP, to the teacher, and to a friend.
Free tools are available for transcribing and analyzing speech samples (see talkbank.org). These tools allow clinicians to perform stuttering calculations and Language Sample Analysis. The CLAN program (MacWhinney, 2000) automatically calculates the frequency of stuttered speech from transcribed samples. In addition, clinicians can use CLAN to obtain information on the child’s language skills via CLAN’s language analysis tools. Bernstein Ratner and MacWhinney (2018) provides detailed guidance on how to use CLAN for fluency measurement.
11. In Question 1 you noted that a speaker’s reactions to their stutter are an important part of the definition of stuttering, and that stuttering influences one’s ability to communicate. What types of reactions should I assess, and how do I go about measuring these reactions to stuttering and communication?
Essentially, you are trying to find out what the child is doing because they stutter. One area to explore is the child’s awareness of their stuttering. Does the child anticipate stuttering? Attempt to avoid it? What coping strategies do they use to manage their stuttering? Another area to explore is the child’s assessment of his communication skills. Does he think of himself as a “good communicator?” Why or why not? How confident is he in communicating with others?
This type of information can be gathered by asking the child (or parent) directly. There are a number of tests that can be administered to evaluate the child’s attitudes toward communication and stuttering, including the Communication Attitude Test (CAT; Brutten & Vanryckeghem, 2007), the Speech Situation Checklist-Emotional Response (SSC-ER; Brutten & Vanryckeghem, 2007), and the Overall Assessment of the Speaker’s Experience of Stuttering-School-Age (OASES-S; Yaruss & Quesal, 2016).
12. I seem to remember that stuttering can be influenced by how people in the child’s environment react to them and to their stuttering. How do I obtain information on this? Who should I solicit information from and what types of questions should I be asking?
You’re absolutely right. In fact, it’s the fifth core area to assess. The reactions that the child receives from people in their environment will influence the child’s experience of stuttering, making this type of information very important to gather from parents, family members, teachers, and peers (Beilby, Byrnes, & Young, 2012). Parents might be asked about their reactions to the child’s stutter, how concerned they are about it, and their perceptions about how the stuttering influences family dynamics. Teachers could be asked about reactions to the child’s stutter that are occurring in the classroom environment. Information about bullying and how it is addressed can be obtained from teachers (and from the child who stutters!). If your assessment suggests that negative environmental reactions to stuttering are present, reducing negative reactions can be targeted in treatment.
13. I see that stuttering has the potential to really impact a kid’s life. I’d like to be able to tell parents, teachers, and school administrators just how stuttering influences aspects of their life overall. Is there some way to measure this?
Assessing the nature and amount of adverse impact that stuttering has on a child’s life is the sixth core area of assessment. Assessing impact can be done in many ways, not the least of which is asking the child how stuttering impacts his communication, his quality of life, and how peer reactions influence his views of himself and his stutter. We might ask teachers how they think stuttering influences the child’s learning. We can also pose questions to parents about how they think their child’s stuttering has affected his life, his willingness to communicate, and his relationships with peers. There are also standardized tests that can be given to assess impact, such as the Overall Assessment of the Speaker’s Experience of Stuttering-School age (OASES-S; Yaruss & Quesal, 2016) or the Behavior Checklist (BCL; Brutten & Vanryckeghem, 2007).
14. How do these six core areas align with the World Health Organization’s ICF Model? ASHA (2016) specifies use of the ICF model in the Scope of Practice for Speech-Language Pathology.
Yes, ASHA sees the ICF as a framework to guide assessment and treatment in speech-language pathology. The ICF has been applied to stuttering (Yaruss & Quesal, 2004). The six core assessment areas described here map on to the ICF quite well. Core areas 1, 2, and 3 address the ICF’s Body Function and Structure sections. The ICF’s Personal and Environmental Contexts are addressed by core areas 4 and 5. Core area 6 relates to the Activities and Participation aspects of the ICF. An assessment addressing each of these areas will result in a well-rounded assessment from which to plan treatment.
15. Wow, it now seems obvious then that stuttering is more than just speech and if we only count stuttered words, we are not completing a holistic assessment. Which core area is the most important to assess?
In the larger sense, no one area is more important than another; this is why we suggest assessing each area as part of a holistic assessment of the child’s stutter. However, a holistic assessment may reveal that a given client’s stuttering is more impacted by the reactions of others, for instance, than by the total number of stuttered words. That is, some core areas may be contributing more than others to the overall impact that the stuttering is having on the child’s life. Discovering this type of information, along with asking the child what they wish the outcome of treatment to be, will lead to more person-centered treatment.
16. I should be asking my kids what they want out of treatment?
Absolutely. They are the experts on their stuttering. They know that they stutter and they know that their communication interactions are different from those of their peers. Clinicians need to acknowledge this and listen to what kids want out of treatment. People’s experiences of stuttering differ (Tichenor & Yaruss, 2019), therefore it’s important to ask clients about what the goals of treatment should be and how to define successful outcomes (Bothe & Richardson, 2011; Rodgers & Gerlach-Houck, 2022; Tichenor, Herring & Yaruss, 2022).
17. What if I am assessing a preschool-aged child? How does the assessment differ?
Well, that might take an additional 20 questions to explain in detail! Perhaps the biggest difference in the assessment of stuttering in this age range is that clinicians need to make a decision about a) whether stuttering is present and b) how likely it is to persist (Manning & DiLollo, 2018). It is beyond the scope of this 20Q paper to discuss variables that might influence stuttering persistence and recovery; for readers interested in learning more on this topic, the work of Walsh and colleagues (2018) and Singer et al (2020) provide guidance on this important topic.
In terms of similarities in the assessment of preschoolers, all six core areas should be assessed with children aged 2-6 years. Caregivers are critical to the assessment of preschoolers. In addition to providing stuttering-specific background information, caregivers can also inform clinicians about how the child’s environment (home, preschool, etc) reacts to the child’s stutter. By completing scales such as the Palin Parent Rating Scales (Millard & Davis, 2016) parents can inform us about how confident they feel in managing the child’s stutter, how they themselves are impacted by their child’s stuttering, and how the stuttering impacts their child. Temperament scales such as the Child Behavior Questionnaire (Rothbart et al, 2001) provide valuable information for use in planning treatment. We can screen for speech, language, and articulation skills using standardized tests, and collect speech samples across a variety of settings to evaluate the variability of stuttering.
Don’t forget to include the child in the assessment process! Even at this young age they very likely have some idea that their speech is different from that of their peers. Clinician’s should explore what the child knows about their stuttering and how it impacts them. Children should also be asked about coping strategies and what they do to manage the stuttering, using age-appropriate language of course!
18. What about adolescents and adults? What are the main differences in the assessment of persons this age?
Informal observation of speech and language skills is appropriate when assessing adolescents and adults. Temperament evaluation is typically not completed for this age range. All the other core areas should be assessed. As in other age ranges, adolescents and adults should be given agency to participate in goal setting and defining what constitutes a successful treatment outcome (Rodgers & Gerlach-Houck, 2022; Sønsterud, et al., 2020).
19. What is the best way to use this article in my clinical practice?
I would suggest printing out Appendices A-E in the article Consensus Guidelines for the Assessments of Individuals Who Stutter Across the Lifespan (Brundage, et al. 2021) and using them to design your assessment plan. The appendices are organized by age and provide examples of how to assess each of the six core areas.
20. Is there work similar to this study addressing stuttering treatment rather than assessment?
Yes! Connery and colleagues (2022) used consensus procedures to develop a framework for stuttering intervention in adults. They identified key components to treatment of stuttering in adults, including, “personal reactions to stuttering, limitations in life participation, and environmental factors” (p. 113). Their findings suggest that affective and cognitive reactions to stuttering, as well coping strategies to address reactions encountered by the stutterer in their environment are critical areas to address in treatment.
In other recent work, Constantino (2022) makes a strong argument that helping children create positive identities as stutterers should be the focus of treatment. Gerlach-Houck and Constantino (2022) provide suggestions on how to incorporate identity work into treatment with stuttering children and adults.
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Brundage, S. (2023). 20Q: Consensus Guidelines for the Assessment of Stuttering Across the Lifespan. SpeechPathology.com. Article 20593. Available at www.speechpathology.com