Fluency Assessment Exam

Case Study 1: Michelle is a young lady of 18. Her father convinced her to seek
treatment for her stuttering since it was interfering with interactions at school and her
social life. She stutters with a great deal of facial contortions and even protrudes her
tongue on long blocks. Although there are situations where she could talk easily, her
stuttering is severe when she talks with her principal, her boss at her part time job, or
anyone else whom she perceives as an authority figure. She feels totally helpless during
moments of stuttering and deeply ashamed afterwards. Michelle wants to be a teacher,
but has decided not to apply to college due to her stuttering issues.Michelles score on
the Erickson Scale was 24 and her mean score on the Avoidance section of the
Stutterers Self Ratings of Reactions to Speech Situations was 3.00. You are seeing
Michelle from an outpatient setting through a local rehabilitation hospital.
Diagnosis: Advanced stuttering

Assessment Measure 1: Princeton Speech-Language & Hearing Center Adult

Fluency Case History Form http://psllcnj.com/pdfs/Adult-Fluency-Case-HistoryForm.pdf
o Rationale: Case history forms for stuttering cases need to be more in
depth. Not only will this specific case history form provide general
information such as identifying information and family history, but
developmental history including the individuals physical and language
development will be provided. The most crucial section to this case
history form may be that which provides information about the fluency
problem. It is common for a true stutter to progressively begin before the
age of 7. If the case history reveals this was not the case, the clinician
may begin to suspect an alternative type of disfluency. Example
questions include describing the onset, the course of development,
description of symptoms, and situations which worsen the amount of
disfluencies. Determining the onset is crucial in differential diagnosis.
Assumptions should never be made. If the onset happened to be sudden,
it would be suggestive of a psychogenic stutter. There is also a section to
describe the home environment which can give the clinician an insight
into the individuals personality, and how she reacts in certain situations.
Relevant case history is a key component to a comprehensive
assessment. Medical and family, as well as development history are
important factors which may contribute to fluency problems. The family
history will be beneficial to determine if anyone in the clients family
stuttered. If so, this helps explain the cause of Michelles current stutter.
Additional questions regarding emotional aspects of the client and
behavioral manipulations can also be addressed if not done so in the
fluency section of the form. This would determine if the individual is
sensitive and demonstrates meltdowns and tantrums. Behavioral
manipulations would provide insight as to whether or not the individual
engages in circumlocutions or tries to avoid specific words. With the right
case study, such as the one suggested above, key information such as
age of onset, type and frequency of duration, and any previous treatment

experiences or outcomes can be determined and can help lead to

differential diagnosis.

Assessment Measure 2: Oral Mechanism Examination

o Rationale: An oral mechanism examination will be performed to ensure
proper structure and function of the oral mechanism. The face, jaw, teeth,
lips, and tongue will be evaluated for symmetry and range of motion. The
pharynx will be examined for appropriate color; the soft and hard palate
will be examined to determine absence or presence of growths (e.g.,
fistula, clefting). Any deviations will determine how the problem should be
treated (e.g., surgery, speech therapy, other physical management). An
absence of deviations allows the clinician to continue the assessment
with knowledge that the oral mechanism has the proper components to
function correctly.

Assessment Measure 3: Hearing Screening

o Rationale: We would want to ensure that a hearing screening was
conducted. This would be important to determine if the individual is
hearing sounds correctly. A hearing loss could result in a delay in speech
and language skills and/or language deficits that may lead to learning
problems. Difficulties in communication may lead to several problems
including social, emotional, and behavioral problems.

Assessment Measure 4: Spontaneous Speech Samples

o Rationale: Spontaneous speech samples will be collected in various
settings. The first will be conducted with Michelles boss at her part-time
job since he is viewed as an authority figure, and Michelle is found to
have increased disfluencies when interacting with authority figures.
Michelle will need to interact with various bosses throughout her lifetime
so this is extremely functional.
The second speech sample will be obtained through conversation with
the clinician. The clinician will identify areas of interest for the client and
discuss them to obtain the sample. The third conversation sample will be
collected between Michelle and her father. The previous three settings
will assess the effect of various communication partners on the clients
disfluencies and identify if an increase in disfluency occurs for each
partner.
Each of these samples will be utilized to identify the type and frequency of
disfluencies and will strive to include a minimum of 100 syllables. If
repetitions and prolongations are present, but not blocks, this may
suggest the stuttering is not as advanced. The clinician would also look
where the disfluencies occur within the word: initially, medially or finally.
When disfluencies occur on the initial or stressed part of a word, it is more
characteristic of developmental stuttering. If disfluencies occur medially or
finally, it could be suggestive of neurogenic stuttering. The clinician will
also be able to identify increased speech rate. Because moments of
stuttering take up time, the speaking rate is reduced. The more frequent
and longer the durations, the greater the effect on rate. If this is the case,
the clinician can analyze the articulatory rate, or rate of speaking when
Michelle is fluent. This rate may represent the target rate in therapy. To
do so, the clinician would count the number of words spoken over two

minutes of fluent speech and divide by two. An increased speech rate

may be representative of cluttering. By analyzing in different settings, the
clinician can view the effect that each setting may have on the severity of
stuttering. The samples will be videotaped so the clinician can observe
any secondary behaviors that occur and can identify if any setting has
secondaries that are specific to that particular setting. The speech sample
will also allow the clinician to obtain baseline data and calculate a
Stuttering Index. The data collected from the speech sample can identify
the severity of the stutter as well as provide target areas for therapy
goals. All spontaneous speech samples will be video recorded in order to
rewatch for physical concomitants.

Assessment Measure 5: Erickson Scale

o Rationale: This test would be administered as an attitudinal scale for
adults. Twenty-four different statements are provided which discuss a
variety of situations, and the person who stutters answers true or false for
each question based on their feelings. The higher the score, the more
negative the attitudes and feelings are towards stuttering. This would be
given to determine Michelles attitudes and feelings and see if this may be
a possible area that needs to be focused on during treatment. Often
times, treatment that does not also take into account feelings can result in
ineffective outcomes.

Assessment Measure 6: Stutterers Self Rating of Reactions to Speech

Situations: Avoidance Section
https://books.google.com/books?id=SgRqERYyXFMC&pg=PA210&lpg=PA210&
dq=stutterers+self+rating+of+reactions+to+speech+situations&source=bl&ots=Kc
dpxlMbGQ&sig=styxyx14cuIrDskQtatLaJYYJHk&hl=en&sa=X&ei=k6WdVayiBYqf
ggS665boCQ&ved=0CF8Q6AEwCQ#v=onepage&q=stutterers%20self%20rating
%20of%20reactions%20to%20speech%20situations&f=false (pg 210)
o Rationale: This would be administered to have a better understanding of
which situations make Michelle most uncomfortable, and in which
situations she is more relaxed. This can be helpful when providing
treatment because techniques would first be taught in unfeared situations.
For this assessment, Michelle would rate the amount of anxiety she feels
towards specified situations. The numbers range from 1 to 5 with 1
meaning she has no desire to avoid the situation, and 5 meaning she
avoids the situation at all costs. By determining which situations are most
comfortable for Michelle, the clinician will have a better understanding of
where to begin with treatment. This may also provide insight as to
whether or not Michelles stuttering is a handicap.

Assessment Measure 7: Reading Assessment in SSI-4

o Rationale: Michelle will be provided with the passage from the SSI as
long as it is within her comfortable reading level. The passage should be
at this level because we do not want to tax her system above the level
she is comfortable. Michelle should be able to easily read the passage at
a comfortable level. She will be required to read the passage through six
times. This assessment will look to provide information as to whether or
not the adaptation effect occurs. This will help the clinician differentially
diagnose what type of stuttering is occurring and help to rule out

neurogenic stuttering if the adaptation effect is not present. It will also

allow the clinician to see if Michelle is avoiding certain sounds or words
that increase stuttering like disfluencies.

Assessment Measure 8: Test of Adolescent and Adult Language- 4th Edition

(TOAL-4)
o Rationale: The TOAL-4 will be used to test Michelles expressive and
receptive language abilities. If Michelles disfluencies are a result of a
language problem then the language problem must be addressed before
treating the stutter in therapy. This information is imperative to know in
order to properly treat the client. The clinician should also take note of the
type and frequency of disfluencies as the tasks during the test increase in
complexity. It is important to note if the stutter increases with increased
language complexity because it will allow the clinician to see the
maximum level of demand that leads to fluency. This can be utilized to
identify target complexities for therapy so that therapy activities are not
too taxing on Michelles system. It will also be an area of possible
education for Michelles father and teachers. A decrease in the demand
put on Michelle may lead to more fluency. If the stutter increases with an
increase in language complexity this could be a result of two different
things. It is known that as children are expected to produce more complex
language, stuttering increases because their systems are being taxed. It
is common that children who stutter also have language delays, but we
want to be able to rule out a language based disfluency. If it is noted that
Michelle has increased difficulty with increased language complexity and
grammatical structure along with disfluencies resulting from word-finding
difficulties, her stutter may truly be a language based disfluency. This
means the target of therapy needs to focus on language based activities
and not stuttering. The stuttering will clear up with increased language
skills. If it is not found that MIchelle demonstrates more difficulty with
increasingly complex language and grammatical structures and
demonstrates word finding difficulties, it can be ruled out that she
presents with a language based disfluency. Although a language based
dysfluency may be ruled out, it is common that children who stutter also
demonstrate delayed language abilities so language still may need to be
addressed in therapy alongside of stuttering therapy.

Assessment Measure 9: Articulation Assessment (Conversational Sample and

Goldman Fristoe if necessary)
o Rationale: It is important to evaluate Michelles articulation in order to rule
out other diagnoses. Delays or disorders in articulation may be related to
the amount of capacities and demands placed on the individual. Oral
motor skills are needed for proper articulation, and if they are not at the
level they should be, articulation may suffer. It is also important to
evaluate articulation because Michelle could be delayed in articulation
which may be why she is presenting with disfluencies. Her fluency may
be suffering because she is trying so hard to be articulate. If this is the
case, working on articulation first may ultimately lead to more fluent
speech. If no articulation errors are observed, cluttering can be ruled out
as a diagnosis. This is because cluttering involves slurring of speech

sounds possibly due to an increased rate of speech which could result in

unintelligibility.
Michelles articulation will initially be assessed informally through a
spontaneous conversational sample. As the clinician speaks with
Michelle, she will note various present articulation errors. If it is
determined that Michelle exhibits articulation errors, the Goldman Fristoe
Test of Articulation-2 will be administered to identify all errors and
substitution patterns.

Assessment Measure 10: Treatment Probe

o Rationale: A treatment probe utilizing various treatment strategies will be
conducted. This may include both fluency shaping techniques and
modification therapy. Techniques may include easy speech,
cancellations, slide and bounce, or pull-outs. Therapy is individualized for
each person, and it is important to utilize various techniques to see which
Michelle responds best to. This probe will be performed in an ABAB
fashion. This will allow the clinician to see which strategies may be
beneficial to the patient and to assist in developing potential goals for
therapy.

Case Study 2: Caleb is a 4 year old boy who has been stuttering for six months,
according to his parents. He stutters on approximately six percent of his spoken words.
His disfluencies are characterized by repetitions and a few prolongations. He is aware of
his stuttering. A few times his friends in the neighborhood had teased him about his
speech. Caleb does not exhibit many word or situation avoidances, but he does use
different ways of speaking to be fluent. For example, he learned that if he spoke in a
high pitched voice, he could be fluent, and from time to time, he does this. During initial
evaluation, he responded well to trail therapy. He was fluent at the word, phrase, and
sentence levels. You are seeing Caleb in a preschool setting.
Diagnosis: Beginning stuttering
Assessment Measure 1: Princeton Speech-Language & Hearing Center
Pediatric Fluency Case History Form
o Rationale: A case history is important to identify any family history,
predisposing, precipitating, and perpetuating factors. Case history forms
for stuttering cases need to be more in depth. Not only will this specific
case history form provide general information such as identifying
information and family history, but developmental history including the
childs physical and language development will be provided. The most
crucial section to this case history form may be that which provides
information about the fluency problem. Example questions include
describing the onset, the course of development, description of
symptoms, and situations which worsen the amount of disfluencies.
Determining the onset is crucial in differential diagnosis. It appears as
though Calebs age suggests developmental stuttering, but it is important
for the clinician to ensure that the onset was gradual. Assumptions should
never be made. If the onset happened to be sudden, it would be
suggestive of a psychogenic stutter or neurological stutter. There is also a
section to describe the home environment which can give the clinician an
insight into the childs personality, and how he reacts in certain situations.

It can provide information about family interactions as well. Relevant

case history is a key component to a comprehensive assessment.
Medical and family, as well as development history are important factors
which may contribute to fluency problems. Additional questions regarding
emotional aspects of the client and behavioral manipulations can also be
addressed if not done so in the fluency section of the form. This would
determine if the child is sensitive and demonstrates meltdowns and
tantrums. Behavioral manipulations would provide insight as to whether or
not the child engages in circumlocutions or tries to avoid specific words.
With the right case study, such as the one suggested above, key
information such as age of onset, type and frequency of duration, and any
previous treatment experiences or outcomes can be determined.

Assessment Measure 2: Oral Mechanism Examination

o Rationale: An oral mechanism examination will be performed to ensure
proper structure and function of the oral mechanism. The face, jaw, teeth,
lips, and tongue will be evaluated for symmetry and range of motion. The
pharynx will be examined for appropriate color; the soft and hard palate
will be examined to determine absence or presence of growths (e.g.,
fistula, clefting). Any deviations will determine how the problem should be
treated (e.g., surgery, speech therapy, other physical management). An
absence of deviations allows the clinician to continue the assessment
with knowledge that the oral mechanism has the proper components to
function adequately and that there are no underlying conditions present.

Assessment Measure 3: Hearing Screening

o Rationale: We would want to ensure that a hearing screening was
conducted. This would be important to determine if the individual is
hearing sounds correctly. A hearing loss could result in a delay in speech
and language skills and/or language deficits that may lead to learning
problems. Difficulties in communication may lead to several problems
including social, emotional, and behavioral problems.

Assessment Measure 4: Spontaneous Speech Samples

o Rationale: The spontaneous speech samples will be obtained in three
different locations. The first will be a play based sample in the speech
classroom. Caleb will be provided with various toys (e.g., trucks, animal
farm, train set, etc.). Caleb and the clinician will play together to elicit a
language sample. The second setting where the spontaneous speech
sample will be conducted will be the classroom setting. This will be
utilized to see how Caleb interacts in the classroom during a group
activity. This sample will allow the clinician to see what types and
frequencies of disfluencies Caleb is producing as well as how his teacher
and peers respond to these disfluencies. The third setting for the
spontaneous speech sample is the home. Calebs parents will be
requested to record a typical part of their day (i.e., meal times, play time,
etc). This sample will allow the clinician to see if the setting has an effect
on the disfluencies. It will also allow the clinician to see the model the
child is receiving from the caregiver. Key factors that can be observed
include the rate of speech, the amount of questions Caleb is asked by his
parents, and how much attention Caleb is given by his parents. It can be

determined if Calebs parents critiqued his moments of stuttering or

placed added pressure on him while such as a demand for fluent speech.
These speech samples will allow the clinician to assess the types and
frequencies of the disfluencies as well as any secondary behaviors that
may accompany the disfluencies. Each of these samples will be utilized to
identify the type and frequency of disfluencies and will strive to include a
minimum of 100 syllables. If repetitions and prolongations are present,
but not blocks, this may suggest the stuttering is not as advanced. The
clinician would also look where the disfluencies occur within the word:
initially, medially or finally. When disfluencies occur on the initial or
stressed part of a word, it is more characteristic of developmental
stuttering. If disfluencies occur medially or finally, it could be suggestive of
neurogenic stuttering. The clinician will also be able to identify if an
increased speech rate. Because moments of stuttering take up time, the
speaking rate is reduced. The more frequent and longer the durations, the
greater the effect on rate. If this is the case, the clinician can analyze the
articulatory rate, or rate of speaking when Beth is fluent. This rate may
represent the target rate in therapy. To do so, the clinician would count
the number of words spoken over two minutes of fluent speech and divide
by two. By analyzing in different settings, the clinician can view the effect
each setting may have on the severity of stuttering. By utilizing three
different situations, the clinician can assess how these secondary
behaviors may vary based on the communication setting or partner. The
clinician will obtain a Stuttering Index from each sample. It will also allow
the clinician to obtain baseline data and identify target areas for therapy.
All spontaneous speech sample will be video recorded in order to rewatch
for physical concomitants.

Assessment Measure 5: Palin Parent Rating Scale (Assessment of feelings and

attitudes for parents) file:///C:/Users/Lauren/Downloads/Millard-DavisCook%20(2).pdf (pg 3)
o Rationale: The Palin Parent Rating Scale is an assessment measure of
attitudes and feelings of the parents. This questionnaire provides
information about how worried the parent is about the childs stuttering. It
also assesses how anxious the parents are about the childs future,
whether they understand what influences the childs stutters, how it
impacts their family. This questionnaire also serves to provide information
about how confident the parents feel about responding to the childs
stutter and how confident they are in encouraging the fluency of the child.
This assessment measure will be used to gauge how the parents feel
towards the childs stutter and their level of understanding of stuttering. It
will serve as a baseline as to what extent the familys reactions to the
stutter need to be modified to encourage fluency in the child. This will
provide background information about the family and their interactions.
The results of this assessment will allow the clinician to see what level of
education they need to provide the parents with. It is important to assess
the level of comfort the parents feel with their childs stutter and identify
any negative reactions and feelings they may have. The clinician can use
this information to assure the parents that Caleb is still capable of being a
successful individual, regardless of his stutter. The clinician may also act
as a resource to ease any guilt the parents may be feeling. The clinician

plays an important role in teaching the family how to interact with their
child in a way that is most beneficial for that child.

Assessment Measure 6: Feelings and attitudes of child through drawing

o Rationale: Caleb will be prompted to draw various pictures depicting his
feelings and attitudes towards himself and his stutter. He will be asked to
draw how he feels when he stutters and how he feels at school when he
stutters. Based on his drawing, questions may be asked to further elicit
his feelings and attitudes. This measure will be utilized to analyze Calebs
feelings about himself and his stutter. This will provide the clinician
information about how being teased has affected Calebs attitudes and
feelings towards stuttering and will provide information as to the extent
that attitudes and feelings need to be targeted in therapy. This will also
allow the clinician and Caleb to establish an important rapport that is
necessary for successful therapy. It is important to assess Calebs
attitudes and feelings to see the extent to which the stutter has affected
him until this point. It is important for the clinician to intervene early so
that these negative attitudes and feelings can be kept to a minimum.

Assessment Measure 7: Clinical Evaluation of Language FundamentalsPreschool, 2nd Edition (CELF-P2)

o Rationale: The CELF-P2 will be administered to assess Calebs receptive
and expressive language abilities. A standardized test to assess these
measures is necessary to identify whether Caleb has a language disorder
in conjunction with his disfluencies. This is pertinent information because
it will provide the clinician with information about Calebs language
abilities and targets for therapy. If Caleb is identified with a language
disorder, it may be beneficial to target the underlying language deficits
before targeting the disfluencies. Improvement of the base language skills
may improve disfluencies as well. The CELF-P2 will also provide
information about Calebs phonological awareness skills, as deficits here
are often seen in conjunction with disfluencies.

Assessment Measure 8: Rote Speech Probe

o Rationale: A rote speech probe will be utilized to rule out neurogenic and
psychogenic disfluencies. Since Caleb is not of age to be a fluent reader,
a reading probe to assess these would not be possible. Instead, Caleb
will be required to repeat rote speech tasks multiple times. For example,
Caleb will be required to count from 1-10 and repeat this 6 times. The
clinician will be looking for the adaptation effect to occur. If the adaptation
effect occurs, the clinician can rule out neurogenic and psychogenic
disorders. This rote speech probe will also be helpful to identify specific
sounds that Caleb may be experiencing difficulty with and may be
avoiding in everyday speech.

Assessment Measure 9: Articulation Assessment - Structured Photographic

Articulation Test - II (SPAT-DII)
o Rationale: The Structured Photographic Articulation Test II will be
administered to assess Calebs articulation abilities. While at this age the
clinician would still expect to see some remaining phonological
processes, the assessment will be used to ensure that Caleb is within the

normal range. This test will be utilized to rule out cluttering, as articulation
difficulties are a characteristic of cluttering. It will also be utilized to
identify therapy targets if Caleb is exhibiting phonological processes that
are not age appropriate.

Assessment Measure 10: Treatment Probe

o Rationale: A treatment probe utilizing various treatment strategies will be
conducted. This may include both fluency shaping techniques and
modification therapy. However, modification techniques will only be
utilized if it is noted that Caleb is exhibiting negative feelings and attitudes
toward stuttering. Techniques may include easy speech, cancellations,
slide and bounce, and pull-outs. Therapy is individualized for each
person, and it is important to utilize various techniques to see which
Caleb responds best to. This probe will be performed in an ABAB fashion.
This will allow the clinician to see which strategies may be beneficial to
the patient and to assist in developing potential goals for therapy.

Case Study 3: Beth is a 3 year old girl who has been referred to your services by her
concerned parents. Results of a case history indicate that there is no family history of
stuttering. Development, according to her pediatrician, has been normal and without
incident. An assessment of her speech and language indicate that she is at a 4 year
level for receptive and expressive language and age appropriate for her articulation and
phonological abilities. A video tape from home and observation of parent and child
interaction in the clinic indicate that the childs parents speak at a fast rate, siblings and
other family members often interrupt, and the familys lifestyle is very hectic. A speech
sample analysis indicates that she stutters on 4% of her syllables. Beth shows no signs
of awareness or frustration. You are seeing Beth in a clinical setting.
Diagnosis: Borderline stuttering

Assessment Measure 1: Princeton Speech-Language & Learning Center:

Pediatric Fluency Case History Form
o Rationale: Although there was no family history noted, it is important to
obtain information from a case history form. Case history forms for
stuttering cases need to be more in depth. Not only will this specific case
history form provide general information such as identifying information
and family history, but developmental history including the childs physical
and language development will also be provided. The most crucial section
to this case history form may be that which provides information about the
fluency problem. Example questions include describing the onset, the
course of development, description of symptoms, and situations which
worsen the amount of disfluencies. Determining the onset is crucial in
differential diagnosis. It appears as though Beths age suggests
developmental stuttering, but the clinician would want to confirm that the
onset was gradual. Assumptions should never be made. If the onset
happened to be sudden, it would be suggestive of a psychogenic or
neurological stutter. The form also has a section which describes the
home environment. This can give the clinician an insight into the childs
personality, and how she reacts in certain situations. Relevant case
history is a key component to a comprehensive assessment. Medical and

family, as well as development history are important factors which may

contribute to fluency problems. Additional questions regarding emotional
aspects of the client and behavioral manipulations can also be addressed
if not done so in the fluency section of the form. This would determine if
the child is sensitive and demonstrates meltdowns and tantrums.
Behavioral manipulations would provide insight as to whether or not the
child engages in circumlocutions or tries to avoid specific words. With the
right case study, such as the one suggested above, key information such
as age of onset, type and frequency of duration, and any previous
treatment experiences or outcomes can be determined.

Assessment Measure 2: Oral Mechanism Examination

o Rationale: An oral mechanism examination will be performed to ensure
proper structure and function of the oral mechanism. The face, jaw, teeth,
lips, and tongue will be evaluated for symmetry and range of motion. The
pharynx will be examined for appropriate color; the soft and hard palate
will be examined to determine absence or presence of growths (e.g.,
fistula, clefting). Any deviations will determine how the problem should be
treated (e.g., surgery, speech therapy, other physical management). An
absence of deviations allows the clinician to continue the assessment
with knowledge that the oral mechanism has the proper components to
function correctly.

Assessment Measure 3:
o Rationale: We would want to ensure that a hearing screening was
conducted. This would be important to determine if the individual is
hearing sounds correctly. A hearing loss could result in a delay in speech
and language skills and/or language deficits that may lead to learning
problems. Difficulties in communication may lead to several problems
including social, emotional, and behavioral problems.

Assessment Measure 4: Spontaneous Speech Sample

o Rationale: Spontaneous speech samples will be collected in various
settings.The sample will be representative of Beths speech in everyday
use. It is important to analyze different settings to see how the amount,
type and duration of disfluencies may vary. First, we suggested a video
recording of a typical time in the home environment. By having the family
provide a recording of their interactions together, the clinician is able to
gain a better understanding of the environment the child is in when at
home. The clinician would look for the interaction between Beth and her
parents and Beth and her siblings. Key factors that can be observed
include the rate of speech of Beth and her parents, the amount of
questions Beth is asked by her parents, and how much attention Beth is
given by her parents. in addition, it can be noted if Beth must compete
with siblings for her parents attention.The clinician would see if Beths
parents critiqued her moments of stuttering or placed an added pressure
on her while talking. This may include a fast rate of speech, numerous
questions, demand for fluent speech or increased interruptions.
Although it might be noted in the previous sample, we would want to
obtain a speech sample between just Beth and her parents, and then
another one between just Beth and her siblings, with no parents. The

clinician would look to see if there was a reduction or increase in the

amount of disfluencies. If one is present, further analysis would be
conducted to determine a possible cause.
We would also want to collect a speech sample between Beth and the
clinician. The clinician will identify areas of interest for the client and
interact in play-based assessment to collect data.
Each of these samples will be utilized to identify the type and frequency of
disfluencies and will strive to include a minimum of 100 syllables. If
repetitions and prolongations are present, but not blocks, this may
suggest the stuttering is not as advanced. The clinician would also look
where the disfluencies occur within the word: initially, medially or finally.
When disfluencies occur on the initial or stressed part of a word, it is more
characteristic of developmental stuttering. If disfluencies occur medially or
finally, it could be suggestive of neurogenic stuttering. The clinician will
also be able to identify if an increased speech rate. Because moments of
stuttering take up time, the speaking rate is reduced. The more frequent
and longer the durations, the greater the effect on rate. If this is the case,
the clinician can analyze the articulatory rate, or rate of speaking when
Beth is fluent. This rate may represent the target rate in therapy. To do
so, the clinician would count the number of words spoken over two
minutes of fluent speech and divide by two. By analyzing in different
settings, the clinician can view the effect each setting may have on the
severity of stuttering. The samples will be videotaped so the clinician can
observe any secondary behaviors that occur and can identify if one
setting has secondaries that are specific to that particular setting. The
speech sample will also allow the clinician to obtain baseline data and
calculate a Stuttering Index. The data collected from the speech sample
can identify the severity of the stutter as well as provide target areas for
therapy goals. All spontaneous speech sample will be video recorded in
order to rewatch for physical concomitants.

Assessment Measure 5: Assessment of feelings and attitudes: Palin Parent

Rating Scale file:///C:/Users/Lauren/Downloads/Millard-Davis-Cook%20(2).pdf
(pg 3)
o Rationale: Because Beth has not shown any signs of awareness or
frustration, and she is only exhibiting borderline stuttering, the clinician
would not want to draw attention to her stutter. However, it is beneficial to
determine Beths parents attitudes towards their daughters stuttering.
Often times, parents may feel guilt or embarrassment, and the clinician
would want to be aware of these feelings. The Palin Parent Rating Scale
includes questions addressing parents level of concern, how anxious
they are about the future, their understanding of what influences her
stuttering, the impact it has on the family, and how confident they are in
responding to the stutter. The parents would rate each question on a
scale of 0-10. A lower number suggests a negative response to the
questions, and 10 relates to more positive responses. Depending on
parent responses, treatment may focus on education to parents about
stuttering, and how they can cope with and react to their child stuttering.
The clinician may act as a resource to ease any guilt the parents may be
feeling. The clinician plays an important role in teaching the family how to
interact with their child in a way that is most beneficial for that child.

Assessment Measure 6: Preschool Language Scales-5th Edition (PLS-5)

o Rationale: Because research has shown a decrease in fluency when
there is a growth in language, a standardized language test should also
be administered. The PLS-5 will be administered to assess Beths
receptive and expressive language skills as well as her phonological
awareness skills. The results of the PLS-5 will help the clinician identify
whether or not Beth has a language impairment. These results will help to
identify target areas for therapy and to help distinguish what the focus of
therapy should be from the start. For instance, if Beth exhibits a language
disorder, her language abilities may be the primary focus for therapy in
the early stages of treatment. As her base skills increase, Beth may
exhibit an increase in fluency as well.

Assessment Measure 7: Rote Speech Counting and Prayer Sample

o Rationale: Automatic speech tasks, such as saying a known prayer, can
help with differential diagnosis. Because Beth is young, we may ask if she
has a certain prayer memorized. If the diagnosis was found to be
stuttering, this would be consistent with relative fluency while reciting this
prayer. When saying this prayer with a different diagnosis, little or no
change would be noted in the amount of disfluencies. This helps to rule
out other diagnoses.

Assessment Measure 8: Articulation Assessment (Goldman Fristoe)

o Rationale: It is important to evaluate Beths articulation in order to rule out
other diagnoses. Administration of this test will provide the clinician a way
of assessing articulation in consonant sounds. Completing the Single
Words Subtest will provide a sample of Beths spontaneous single-word
elicitation in response to pictures. Delays or disorders in articulation may
be related to the amount of capacities and demands placed on the child.
Oral motor skills are needed for proper articulation, and if they are not at
the level they should be, articulation may suffer. It is also important to
evaluate articulation because Beth could be very delayed in articulation
which may be why she is presenting behind in fluency. Her fluency may
be suffering because she is putting a great deal of effort into being
articulate. If this is the case, working on articulation first may ultimately
lead to more fluent speech. If no articulation errors are observed,
cluttering can be ruled out as a diagnosis. This is because cluttering
involves slurring of speech sounds which could result in unintelligibility.

Assessment Measure 9: Treatment probe in the form of trial Interactions with

parents to see how Beth responds to conversation with reduced stress.
o Rationale: Because Beth is unaware of her stutter and exhibits no
negative feels or frustration, we would not want to draw attention to the
disfluencies. Parents play a key role, and by assessing Beths parents
ability to follow clinician models and learn helpful techniques the clinician
may conclude that parent education would be the most beneficial
technique to increase Beths therapy. It would be important for the
clinician to evaluate the parents perspective, and see how likely they are
to incorporate these techniques in Beths day-to-day routines.

Case Study 4: Brad is a 12 year old boy who stutters with repetitions, prolongations, and
silent blocks. Brad is starting to fear his stuttering and often refuses to answer questions
in class and does not volunteer answers. Results of the Communication Attitude Test = a
score of 35. Brads teacher indicates that his stuttering affects his performance in class
and his interactions with his peers, but specific details are unknown. As a school-based
speech-language therapist, Brad has been referred to your services by his homeroom
teacher. You also discover that Brad is being teased and bullied by a classmate.
Diagnosis: Intermediate stuttering

Assessment Measure 1: Stuttering Case History- Child form

o Rationale: This form will provide insight into Brads medical, family, and
developmental history. Looking at his parents response to the medical
history may provide a reason to suspect neurological stuttering.
Observing his familial history may provide reason to suspect that
stuttering is something that does or does not run in his family. This may
provide part of the etiology of the stutter. Looking at his developmental
history will show the age he began stuttering and what other skills were
developing at the same time. We may also be able to observe various
events surrounding the onset that may lead us to suspect another factor
influencing the development of the stutter. This will show us whether the
stutter developed suddenly which is less indicative of typical stuttering or
gradually which is consistent with stuttering.

Assessment Measure 2: Oral Mechanism Examination

o Rationale: An oral mechanism examination will be performed to ensure
proper structure and function of the oral mechanism. The face, jaw, teeth,
lips, and tongue will be evaluated for symmetry and range of motion. The
pharynx will be examined for appropriate color; the soft and hard palate
will be examined to determine absence or presence of growths (e.g.,
fistula, clefting). Any deviations in the lips, palate, uvula, jaw, tongues,
etc. will determine how the problem should be treated (e.g., surgery,
speech therapy, other physical management). An absence of deviations
allows the clinician to continue the assessment with knowledge that the
oral mechanism has the proper components to function correctly.

Assessment Measure 3: Hearing Screening

o Rationale: We would want to ensure that a hearing screening was
conducted. This would be important to determine if the individual is
hearing sounds correctly. A hearing loss could result in a delay in speech
and language skills and/or language deficits that may lead to learning
problems. Difficulties in communication may lead to several problems
including social, emotional, and behavioral problems.

Assessment Measure 4: Spontaneous Speech Sample

o Rationale: Spontaneous speech samples will be collected in Brads
classroom, home, and in the speech room. It is important to assess
language in various situations because fluency can be altered in regards
to amount, type, and duration of disfluencies depending on the situation.
The three samples mentioned will be representative of Brads speech in
everyday use. First, it is suggested that a video recording of a typical time

in the home environment is conducted. By having the family provide a

recording of their interactions together, the clinician is able to gain a
better understanding of the childs home environment. The clinician would
look for the interaction between Brad, his parents, and his siblings. Key
factors that can be observed include the rate of speech of Brad and his
parents, the amount of questions Brad is asked by his parents, and how
much attention Brad is given by his parents. in addition, it can be noted if
Brad must compete with siblings for his parents attention. The clinician
would observe Brads parents reactions to his moments of disfluency. It
would be noted whether or not his parents critiqued his moments of
stuttering or placed an added pressure on him while talking. The inclusion
of a fast rate of speech, numerous questions, demand for fluent speech
or increased interruptions may cause anxiety and lead to more moments
of disfluency and may provide insight into the etiology of Brads
disfluencies.
We would also want to collect a speech sample between Brad and the
clinician. The clinician will identify areas of interest for the client and
interact in conversation-based assessment to collect data and identify
Brads moments of disfluencies.
Lastly, Brads teacher will be asked to video record 30 minutes of a
classroom discussion. Brads willingness to raise his hand will be noted.
His teachers and peers responses will also observed. It will be important
to recognize how Brad is viewed and treated in the classroom. This will
be important to understanding feelings and attitudes that may come along
with Brads moments of disfluencies. If negative reactions are observed
by others in the classroom, the clinician will provide the teacher with
resources and an education to help minimize these responses. She will
also know to prepare Brad for classroom situations through role play.
Each of these samples will be utilized to identify the type and frequency of
disfluencies and will strive to include a minimum of 100 syllables. If
repetitions and prolongations are present, but not blocks, this may
suggest the stuttering is not as advanced. The clinician would also look
where the disfluencies occur within the word: initially, medially or finally.
When disfluencies occur on the initial or stressed part of a word, it is more
characteristic of developmental stuttering. If disfluencies occur medially or
finally, it could be suggestive of neurogenic stuttering. The clinician will
also be able to identify if an increased speech rate is present.
By analyzing in different settings, the clinician can view the effect each
setting may have on the severity of stuttering. The samples will be
videotaped so the clinician can observe any secondary behaviors that
occur and can identify if one setting has secondaries that are specific to
that particular setting. The speech sample will also allow the clinician to
obtain baseline data and calculate a Stuttering Index. The data collected
from the speech sample can identify the severity of the stutter as well as
provide target areas for therapy goals.

Assessment Measure 5: Teacher Checklist- Fluency

(http://www.isastutter.org/CDRomProject/teacher/guide.html)
o Rationale: It has been noted that Brads disfluencies are impacting his
education. It is possible that when Brad enters into a one-on-one situation
with the speech language pathologist that he will not exhibit significant

disfluencies. Because of this, it is important to know the concerns of the

professional who is working with Brad on an everyday basis. This
checklist will allow Brads classroom teacher to express her concerns and
explain how disfluencies are affecting him in his everyday life. This will be
valuable information to know when planning therapy. It will also provide
insight into how the teacher and other students feel and react when the
student stutters. This is important to know because it may be necessary
to educate the teacher and other students if they are uninformed about
stuttering and how to interact with a person who stutters. This information
may also be beneficial when talking to Brad about his feelings and
attitudes associated with stuttering.

Assessment Measure 6: The Cognitive, Affective, Linguistic, Motor, and Social

Assessment (CALMS)
o Rationale: The CALMS tests childrens ability to identify moments of
stuttering, their knowledge about stuttering, and their knowledge of
previously learned techniques to reduce their stutter. This will reveal
Brads awareness. If he is unaware of exactly when moments of
disfluency occur this will be an early focus of therapy. It will also be
beneficial to determine Brads knowledge about stuttering. Educating
children about what is going on helps them to cope with their stutter and
move forward. This section of the test also provides insight into the
current techniques and their usefulness.
The CALMS also assess childrens attitudes toward stuttering. Research
has found that stuttering is found to resurface in children who had not
addressed their associated feelings in therapy. This will provide baseline
information and give insight into the amount of attention should be
focused on addressing feelings depending on the severity of his attitudes
regarding his stutter.
The CALMS looks at the relationship between the level of complexity of
linguistic information and the frequency of stuttering. This is important to
know what kind of language should be addressed in therapy and to
provide the client with temporary compensatory strategies. This section
also provides an informal measure of the childs general language skills
and of the childs speech sounds production skills. This is important
information because insufficient language skills may be the cause of the
stutter or may be a factor that accompany the stutter that also needs to
be targeted in therapy. If it is determined that the child does not have
articulation errors or language concerns then both cluttering and
language based disfluencies can be ruled out as the actual diagnosis. If
these problems exist, they will need to be addressed before treating the
stuttering behaviors or alongside of the fluency treatment if they are minor
and not the cause of the stutter.
It also provides information regarding types of disfluencies,
average number of unit repetitions per repetition, the tempo and regularity
of repeated units, and the average degree of tension, struggle, and effort
exhibited during a stuttered moment. This information will be beneficial to
diagnosis whether or not the client stutters and if a true strutter is present
it will help determine the present level of stuttering. It will also be useful

baseline information to reference periodically throughout therapy to track

progress.
Lastly, it looks at how often the child avoids words, people, and
speaking situations and how stuttering increases or decreases in those
various atmospheres. It also looks at the affects the stutter has on the
childs ability to make and keep friendships. This will be key information in
determining Brads feelings and attitudes about stuttering and whether or
not these attitudes need to be addressed in therapy.

Stutterers Self Rating of Reactions to Speech Situations: Avoidance Section:

https://books.google.com/books?id=SgRqERYyXFMC&pg=PA210&lpg=PA210&
dq=stutterers+self+rating+of+reactions+to+speech+situations&source=bl&ots=Kc
dpxlMbGQ&sig=styxyx14cuIrDskQtatLaJYYJHk&hl=en&sa=X&ei=k6WdVayiBYqf
ggS665boCQ&ved=0CF8Q6AEwCQ#v=onepage&q=stutterers%20self%20rating
%20of%20reactions%20to%20speech%20situations&f=false (pg 210)
o Rationale: This would be administered to have a better understanding of
which situations make Brad most uncomfortable, and in which situations
he is more relaxed. This can be helpful when providing treatment
because techniques would first be taught in unfeared situations. For this
assessment, Brad would rate the amount of anxiety he feels towards
specified situations. The numbers range from 1 to 5 with 1 meaning he
has no desire to avoid the situation, and 5 meaning he avoids the
situation at all costs. By determining which situations are most
comfortable for Brad, the clinician will have a better understanding of
where to begin with treatment. This will also be beneficial in diagnosing
Brads stage of stuttering. It will provide insight into whether or not Brads
stuttering is handicapping. This may also be used to rule out neurogenic
and psychogenic stuttering if feelings of anxiety are noted. It is known the
neurogenic stuttering may be accompanied by feelings of annoyance but
clients do not appear anxious and attitudes about stuttering are indifferent
in psychogenic stuttering.

Assessment Measure 7: Test of Language Development: Intermediate-4

o Rationale: The TOLD-I-4 will be used to test Brads expressive and
receptive language abilities. If Brads disfluencies are a result of a
language problem then the language problem must be addressed before
treating the stutter in therapy. This information is imperative to know in
order to properly treat the client. The clinician should also take note of the
type and frequency of disfluencies as the tasks during the test increase in
complexity. It is important to note if the stutter increases with increased
language complexity because this could be a result of two different things.
It is known that as children are expected to produce more complex
language, stuttering increases because their systems are being taxed. It
is common that children who stutter also have language delays, but we
want to be able to rule out a language based disfluency. If it is noted that
Brad has increased difficulty with increased language complexity and
grammatical structure along with disfluencies resulting from word-finding
difficulties, Brads stutter may truly be a language based disfluency. This
means the target of therapy needs to focus on language based activities
and not stuttering. The stuttering will clear up with increased language
skills. If it is not found that Brad demonstrates more difficulty with

increasingly complex language and grammatical structures and

demonstrates word finding difficulties, it can be ruled out that Brad
presents with a language based disfluency. Although a language based
dysfluency may be ruled out, it is common that children who stutter also
demonstrate delayed language abilities so language still may need to be
addressed in therapy alongside of stuttering therapy.

Assessment Measure 8: Reading Assessment in SSI-4

o Rationale: Brad will be provided with the passage from the SSI as long as
it is within his comfortable reading level. The passage should be at this
level because we do not want to tax his system above the level he is
comfortable. Brad should be able to easily read the passage at a
comfortable level. He will be required to read the passage through six
times. This assessment will look to provide information as to whether or
not the adaptation effect occurs. This will help the clinician differentially
diagnose what type of stuttering is occurring and help to rule out
neurogenic stuttering if the adaptation effect is present. It will also allow
the clinician to see if Brad is avoiding certain sounds or words that
increase stuttering like disfluencies. Brad will be unable to avoid words
when presented with a reading passage because the clinician will see the
prompt. If Brad constantly stutters on certain words or sounds that are not
seen in his conversational speech, he may be avoiding these words and
sounds to prevent disfluencies. This will be valuable information in
planning therapy. If Brad is avoiding certain words, the clinician will want
to find out the reason why and address the feared words in therapy once
he is comfortable with non feared words.

Assessment Measure 9: Articulation Assessment/Rate of Speech Assessment

(Conversational Sample and Goldman Fristoe if necessary)
o Rationale: It is important to evaluate Brads articulation in order to rule out
other diagnoses. Delays or disorders in articulation may be related to the
amount of capacities and demands placed on the child. Oral motor skills
are needed for proper articulation, and if they are not at the level they
should be, articulation may suffer. It is also important to evaluate
articulation because Brad could be very delayed in articulation which may
be why he is presenting with disfluencies. His fluency may be suffering
because he is trying so hard to be articulate. If this is the case, working
on articulation first may ultimately lead to more fluent speech. If no
articulation errors are observed and a normal rate of speech is observed,
cluttering can be ruled out as a diagnosis.
Brads articulation and rate of speech will initially be assessed
informally through a spontaneous conversational sample. As the clinician
speaks with Brad, she will note various present articulation errors. She
will also record the speech sample so she can calculate his rate of
speech at the conclusion of testing. If it is
determined that Brad exhibits articulation errors, the Goldman Fristoe
Test of Articulation-2 will be administered to identify all errors and
substitution patterns.
If Brad does not present with articulation errors or an increased
rate of speech cluttering can be ruled out as a possible diagnosis. This is

because cluttering involves slurring of speech sounds possibly due to an

increased rate of speech which could result in unintelligibility.

Assessment Measure 10: Treatment Probe (Reduced Speech Rate Probe,

Instructional Control Probe, Prolonged Speech Probe, Self-recording probe)
o Rationale: This treatment probe will evaluate fluency under different
conditions that are known to influence fluency and provide insight into
how similar Brad is to a typical stutterer. It will provide the clinician with
information regarding potentially effective treatment options for him. The
reduced speech rate probe will reveal if Brad benefits from slowing his
speech and increasing pause time. The instructional control probe will
give the clinician insight into how easy it is for Brad to improve fluency
when he is really concentrating and trying to improve. Many clients will
find that it is a stressful situation to focus on avoiding moments of
stuttering and this may increase stuttering. It will be beneficial to know
how concentration on facilitating success impacts Brad when planning
therapy. His reactions during the assessment probe may reveal that
focusing attention to stuttering may be a good environment to avoid
initially and address as the client becomes more confident. This probe will
also provide insight into what the client believes will facilitate success. If
the client is using appropriate techniques, the clinician can perfect the
techniques in therapy, but if the client is using inappropriate techniques
such as secondary behaviors the clinician will know to address this in
therapy.The prolonged speech probe will provide insight into whether or
not prolonging speech is something comfortable and beneficial to Brad.
Lastly, the self-recording probe will alert the clinician to Brads awareness
of his disfluent moments. The clinician will know whether or not teaching
awareness will need to be addressed in therapy before moving onto more
complex objectives. These probes will be used to begin to develop a plan
for therapy. As needed, the clinician will think on her feet and probe
various treatment probes if she is unsuccessful with the previously
mentioned probes and believes the client would benefit best from a
different type of therapy.
References

Guitar, B. (2006). Stuttering: An integrated approach to its nature and treatment (3rd
ed.). Baltimore: Lippincott Williams & Wilkins.