Assessment of Stuttering Disorders in Children and Adults ® Chapter in A Guide to Clinical Assessment and Professional Report Writing in Speech-Language Pathology.

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CHAPTER
347
KEY WORDS
Accessory behaviors, Avoidance
behaviors, Between- word
disfl uencies, Blocks, Broken
words, Clusters, Cluttering,
Core behaviors, Disfl uency,
Dysfl uency, Escape behaviors,
Incipient stuttering, Interjections,
Locus of control of behavior
(LCB), Prolongations, Real- time
analysis, Repetition, Revisions,
Running starts, Spontaneous
recovery, Stutter- like disfl uencies
(SLDs), Tremors, Within- word
disfl uencies
Assessment of
FLUENCY
DISORDERS
13
Naomi Eichorn,M.S., CCC/SLP, TSSLD
Adjunct Lecturer
Department of Speech, Language
and Hearing Sciences
Lehman College of he City University of New York
Speech-Language Pathologist
Adler, Molly, Gurland, LLC
Renee Fabus,Ph.D., CCC-SLP, TSHH
Assistant Professor
Department of Speech Communication Arts
and Sciences
Brooklyn College of the City University of New York
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348 CHAPTER 13
INTRODUCTION
Among the diverse speech and language disorders
we work with as clinicians, fl uency disorders seem to
maintain a sense of ambiguity and challenge. We have
certainly made great strides in understanding various
potential causes of stuttering; nevertheless, a defi nitive
notion of its etiology continues to elude researchers. By
its very nature, stuttering is a condition of inherent con-
trasts. It involves surface features that are easily acces-
sible for measurement and analysis, but is almost always
complicated by a vast underlying set of emotions that
are more diffi cult to label and organize but that are crit-
ical to our assessment and treatment. Sheehan (1970,
p.14) aptly described overt characteristics of stuttering
as “the tip of the iceberg,” an analogy that highlights the
need for clinical protocols that take into account both
symptoms that are perceptible as well as those that may
be more challenging to observe, but that play a critical
role in driving the development of this disorder.
Our aim in this chapter is to present clinicians with
an accessible assessment guide that, in the tradition of
Sheehan’s metaphor, considers both surface and under-
lying symptoms associated with stuttering. It is our hope
that clinicians reading this chapter will feel empowered
to help clients and parents through the diagnostic pro-
cess more eff ectively and be able to mitigate the con-
fusion and frustration often complicating this journey.
Like many other challenging experiences, the process
of understanding and to treat stuttering, often spurs a
deep and ultimately rewarding form of self- exploration
in which individuals who stutter discover, examine,
and learn to change certain attitudes and psychological
tendencies. It is a unique experience to be a catalyst for,
and to be a part of this process.
In the sections that follow, we provide an overview
of stuttering disorders and describe a number of key
parameters considered during the assessment process.
We then review the specifi c components of an evalua-
tion for three age groups: preschool children, school- age
children, and adults. Our discussion will focus primarily
on stuttering disorders, rather than related fl uency dis-
orders such as cluttering, neurogenic stuttering, or psy-
chogenic stuttering, although we do briefl y consider the
diff erential diagnosis of stuttering and cluttering. For
more information on any of these topics, please see the
suggested reading list and websites provided at the end
of this chapter.
DEFINING STUTTERING
Most laypeople describe stuttering as chronic inter-
ruptions in the rhythm, fl ow, or fl uency of speech.
Researchers too, have traditionally defi ned stuttering
based on these general parameters (e.g., Andrews et al.,
1983; Cordes, 2000; Sommer, Koch, Paulus, Weiller, &
Buchel, 2002). What complicates this understanding is
that many of the behaviors observed in the speech of
stutterers are, to some extent, observed in all speakers
(Ambrose & Yairi, 1999; Wingate, 1964; Yairi, 1997).
Ultimately, much of what we call “stuttering” is based
on listener perceptions of what constitutes “typical” or
“atypical” types of interruptions in the fl ow of speech as
well as listener- defi ned norms for the frequency with
which these can occur before they become exceedingly
distracting. As stated by Bloodstein (1995, p. 10), stut-
tering may be defi ned as “whatever is perceived as stut-
tering by a reliable observer who has relatively good
agreement with others.”
Despite an ongoing lack of consensus, certain
aspects of stuttering have been identifi ed as critical to
its defi nition and diagnosis. In one description of stut-
tering provided by the American Speech- Language-
Hearing Association’s (ASHA) Special Interest
Division for Fluency (ASHA, 1999), emphasis is
placed on the specifi c types of disfl uency that are pres-
ent: “Stuttering refers to speech events that contain
monosyllabic whole- word repetitions, part- word rep-
etitions, audible sound prolongations, or silent fi xations
or blockages.  ese may or may not be accompanied by
accessory (secondary) behaviors (e.g., behaviors used to
escape and/or avoid these speech events).” According
to Starkweather and Givens- Ackerman (1997), stut-
tering refers to discontinuities in speech that are not
only excessive in frequency and duration, but also add
an unusual amount of physical and mental eff ort to the
act of speech production. In his classic defi nition, Van
Riper (1982) suggested that stuttering “called attention
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ASSESSMENT OF FLUENCY DISORDERS 349
FLUENCY DISORDERS
13
to itself ” and distracted listeners from the intended
message. Certain researchers (Perkins, Kent, & Curlee,
1991) have emphasized the need to look beyond all
objective speech and nonspeech behaviors and defi ne
stuttering as disruptions of speech in which the speaker
experiences a loss of control.  is chapter attempts to inte-
grate the various notions of stuttering described in the
literature and will be based upon the understanding that
stuttering involves not only a characteristic set of mea-
surable behaviors but also certain subjective experiences
and perceptions that take on increasingly greater signif-
icance as a child grows and his or her stuttering evolves.
 is perspective is refl ected in the International
Classifi cation of Functioning, Disability, and Health devel-
oped by the World Health Organization (WHO, 2001),
which recognizes that complex disorders, such as stutter-
ing, involve not only physical impairment in structure or
function, but also limitations on an individual’s activities
and restrictions on hi s or her par tici pat ion in l ife .  is more
holistic approach encourages us to look beyond superfi cial
behaviors observed in people who stutter and consider
the broader health experience and real- life, everyday chal-
lenges associated with this disorder.  is concept has been
used as the basis for a number of assessment profi les and
scales, and is discussed further in our review of specifi c
assessment measures later in this chapter.
Shapiro (1999, pp. 9–12) identifi es three broad cat-
egories of stuttering defi nitions: (1) descriptive defi ni-
tions, which focus on visible and/or audible stuttering
behaviors; (2) explanatory defi nitions, which emphasize
feelings and attitudes in the person who stutters; and
(3) combined descriptive and explanatory defi nitions,
which include both aspects of the disorder.  e sections
that follow describe an approach to the assessment of
stuttering disorders that represents a combined descrip-
tive and explanatory perspective to stuttering; that is, we
present methods for measuring and understanding both
overt and covert symptoms that may be present.
In defi ning stuttering, it is also useful to diff erenti-
ate between the terms dis uency and dys uency. W hile
the words are sometimes used interchangeably (often
incorrectly), they are distinct in meaning.  e prefi x dis-
implies a lack of something or the opposite of some-
thing; disfl uency, thus, refers to speech that is simply
not fl uent.  e prefi x dys- has a more clearly negative
connotation and refers to something atypical, diffi cult,
or bad. Dysfl uency, thus, implies that the lack of fl uency
is deemed abnormal. In general, it is preferable to use
the term disfl uency because this term encompasses both
speech interruptions that are normal as well as those that
may be abnormal. Referring to speech behaviors as “nor-
mal dysfl uency” is obviously incorrect, as this phrase rep-
resents an inherent contradiction of terms (see Guitar,
2006, p. 5, and Quesal, 1988, for further detail on this
topic). In this chapter, we will use the word disfl uency to
refer to all discontinuities in speech production, whether
typical or atypical. Disfl uencies that clearly represent a
fl uency disorder will be referred to as stuttering.
ONSET AND PREVALENCE
OF STUTTERING
Although a great deal of vagueness persists in how we
defi ne stuttering, there is much that we do know about
the disorder and has been confi rmed consistently over
years of research. First, large numbers of typically devel-
oping young children demonstrate normal speech dis-
fl uencies between the ages of 2 and 5 years (Ambrose &
Yairi, 1999), when they are experiencing rapid growth
in the areas of speech and language. Early signs of stut-
tering, or incipient stuttering, are most likely to occur
during this same period, when children are beginning
to combine three or more words together (Bloodstein,
2006), and are diff erentiated from normal disfl uencies
based on specifi c speech characteristics that will be
described in more detail in the following sections.  e
prevalence of stuttering is also highest among preschool
children compared to school- age children and adults,
with estimated prevalence rates of approximately 2.4%,
1%, and less than 1% for the three age groups, respec-
tively (Andrews et al., 1983; Beitchman, Nair, Clegg, &
Patel, 1986; Bloodstein & Bernstein Ratner, 2008, p. 79).
 ese age- based variations reveal another important
fact about stuttering that becomes critical in the diag-
nostic process, which is that numerous preschool chil-
dren who stutter experience “natural” or spontaneous
recovery without any formal intervention or treat-
ment. A prospective study by Kloth and colleagues
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350 CHAPTER 13
(Kloth, Kraaimaat, Janssen, & Brutten, 1999), for
example, found that stuttering symptoms subsided in
70% of young stuttering children followed over a 6- year
period. Numerous researchers (e.g., Ramig, 1993) have
suggested that recovery rates may be somewhat more
modest; however, it is well accepted that a young child
who stutters is by no means destined to a lifetime of
stuttering.  is situation has made it imperative for
researchers and clinicians to identify factors related to
the child or to the child’s stuttering that might predict
its chronicity or its likelihood to be outgrown.
Of all the child- related and speech- related vari-
ables examined in the literature, the factor most reliably
associated with recovery is the child’s gender, with girls
being far more likely to outgrow early stuttering and
boys being more likely to persist. Male- to- female ratios
appear to be approximately equal at or near the onset
of stuttering (Kloth etal., 1999) but steadily increase
as children get older, with ratios ranging from 3:1 to
5:1 during school years, and higher ratios in adulthood
(Andrews etal., 1983; Bloodstein & Bernstein- Ratner,
2008, p. 79; Curlee, 1999).  is pattern is consistent
with gender diff erences reported for a variety of other
neurodevelopmental disorders (e.g., Baron- Cohen,
2008; Halpern, 1997; Shaywitz etal., 1995). Research
in the area of early stuttering has identifi ed numerous
additional factors associated with greater likelihood
for recovery; these are reviewed later in our section on
assessment of stuttering in preschool children.
CHARACTERISTICS
OF STUTTERING:
GENERAL SYMPTOMS
Reported rates of spontaneous recovery vary widely in
the literature, but it is clear that a considerable number
of young children with disfl uencies will develop chronic
stuttering.  is section will provide an overview of gen-
eral symptoms and characteristics of stuttering disorders
and outline details to help clinicians diff erentiate between
typical and atypical forms of disfl uency.  ree critical
groups of symptoms will be reviewed: core behaviors of
stuttering, accessory behaviors, and emotional reactions.
Core Behaviors
 e key feature of stuttering is the presence of invol-
untary discontinuities in the fl ow of speech.  ese are
traditionally called core behaviors (Van Riper, 1982)
and consist of three basic symptoms: repetitions, pro-
longations, and blocks.
Of all the core behaviors, repetition is the most
common form of disfl uency observed in both typically
developing children as well as children who are dem-
onstrating early stuttering (Ambrose & Yairi, 1999;
Bloodstein & Bernstein Ratner, 2008, p. 31). Repetitions
may occur at the phrase, single- word (single- syllable
word and multi- syllabic words), syllable, or sound level.
 e size of the speech unit aff ected plays an important
role in classifying the disfl uency as typical or atypical.
In general, the smaller the unit being repeated, the more
likely it is that the behavior represents stuttering.  is
concept is considered further in our later discussion on
stutter- like dis uencies (SLDs).
Prolongations are disfl uencies in which sound or
airfl ow continues but movement of the articulators
is stopped, and can occur on continuant consonants
(s, f, th, sh, v, z, w, r, l, y) or vowels. Prolongations are
generally judged by listeners to be an atypical form of
disfl uency (Cordes, 2000) and are most often observed
later than repetitions, although they are sometimes
reported at the onset of stuttering as well (Yairi, 1997).
Blocks involve stopping of both airfl ow and sound
during the production of speech. Blocks are usually the
last core symptom to be observed in the development
of stuttering and are almost always perceived by listen-
ers as an abnormal type of disfl uency. Some researchers
(e.g., Schwartz, 1974) have suggested that blocking is
caused by inappropriate tensing of muscles at the level of
the glottis; however, others believe this obstruction may
occur at the respiratory, laryngeal, and/or articulatory
levels of speech production (e.g., Guitar, 2006, p. 15).
Tw o a dd i ti on a l b eh a vi or s ma y b e ob se r ve d in in d i-
viduals who stutter. Both tend to be somewhat less com-
mon and are generally perceived as atypical (Cordes,
2000). Broken words are blockages in the middle of a
vowel, during which there is audible laryngeal tension,
followed by abrupt reinitiation of the vowel. Tremors,
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ASSESSMENT OF FLUENCY DISORDERS 351
FLUENCY DISORDERS
13
often observed in individuals with advanced forms of
stuttering, involve rapid fasciculations (small involun-
tary contractions or twitching) of the speech muscles.
A fi nal group of disfl uencies includes behaviors that are
less likely to be considered atypical based on listener per-
ceptions (Cordes, 2000; Zebrowski & Conture, 1989), but
that may occur with excessive frequency in the speech out-
put of people who stutter.  ese behaviors are sometimes
categorized as forms of avoidance (discussed in more detail
later in the chapter) rather than core behaviors because
they may represent attempts on the part of the speaker
to gain control of his or her speech or avoid an antici-
pated block.  ese disfl uencies include: (1) interjections
(often called “fi llers”), in which speakers insert extrane-
ous, meaningless words or phrases such as “um,” “you
know,” or “like” into the fl ow of connected speech;
(2) running starts, in which speakers return once or sev-
eral times to the beginning of a thought or sentence in
an attempt to regain fl uency; and (3) revisions, in whic h
phrases or whole sentences are reformulated, often to
avoid anticipated diffi culties on specifi c words or sounds.
Because many of the disfl uencies just described are
observed in normal speakers, a great deal of eff ort has
been made by both researchers and clinicians to dis-
tinguish between those behaviors that are more likely
or less likely to represent symptoms of stuttering. One
classifi cation system reviewed by Zebrowski and Kelly
(2002) divides disfl uencies into two broad categories:
(1) between- word dis uencies, which include all diffi -
culties that occur while a speaker is attempting to link
words together (phrase repetitions, interjections, run-
ning starts, revisions); and (2) within- word dis uencies,
which include all discontinuities that interfere with
the smooth transitioning between sounds or syllables
within a word (sound repetitions, syllable repetitions,
prolongations, blocks, broken words).
Within- word disfl uencies are sometimes called
stutter- like disfl uencies (SLDs) ( Yairi, 1997) and are gen-
erally understood to be more associated with chronic
forms of stuttering. Accurate classifi cation of whole-
word repetitions is somewhat ambiguous (e.g., see
Wingate, 2001); however, most researchers categorize
repetition of single- syllable words as within- word dis-
fl uencies or SLDs and repetition of multi- syllabic words
as a form of between- word disfl uency (e.g., Wingate,
1964). Table13- 1 summarizes the various forms of
Table13- 1. Types of Dis uency.
CORE BEHAVIOR Example
Between vs. Within-
Word Dis uency
Stutter- Like
Dis uency
Phrase repetition “I want- I want to go now” Between No
Word repetition (multi- syllabic) “Cinnamon- cinnamon- cinnamon and sugar” Between No
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  xed articulatory
posture for subsequent sound) want some?”
Within Yes
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
to the fair”
Between No
Revision “I really like to- I really love ice cream” Between No
© Cengage Learning 2012
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352 CHAPTER 13
disfl uency and provides examples of each behavior and
their classifi cation based on the two systems presented.
Accessory Behaviors
As disfl uencies persist, the person who stutters begins
to develop an awareness of his or her diffi culties. It is
at this point that the disorder starts to become more
complex and often more severe, as layers of percep-
tions, expectations, feelings, and attitudes begin to
take root beneath the surface symptoms.  e emer-
gence of accessory behaviors is often one of the
fi rst signs that a child’s stuttering is probably not
developmentally typical (Zebrowski & Kelly, 2002,
pp. 15–16) and that it has progressed from its earli-
est form.  ese behaviors, sometimes referred to as
secondary behaviors, secondary stuttering characteristics,
secondary mannerisms, extraneous behaviors, or concom-
itant behaviors, represent the reaction of the person
who stutters to his or her speech diffi culties and usu-
ally begin as a random struggle, through which the
speaker tries to push out of involuntary repetitions,
prolongations, and blocks.
Over time and with repetition, these behaviors are
reinforced and become learned patterns that accom-
pany core disfl uencies.  ese behaviors may take the
form of speech- related movements, such as lip pressing,
lip pursing, or teeth clenching; extraneous body move-
ments, such as eye blinking, head jerking, fi st clench-
ing, or stamping; or stereotypic speech utterances, such
as interjections, running starts, or circumlocutions, in
which the speaker uses evasive or wordy substitutions
to avoid an anticipated disfl uency. According to Guitar
(2006, p. 16), accessory behaviors can be described
as either escape behaviors or avoidance behaviors.
Escape behaviors represent the speaker’s attempt to
release him- or herself from the block (e.g., by blink-
ing, moving the head, or stamping the feet). Avoidance
behaviors, on the other hand, are used to circumvent
the moment of disfl uency altogether and may include
behaviors previously used as escapes or new behaviors
such as substituting words, postponing feared words, or
using starters. Table13- 2 summarizes these categories
of accessory behaviors.
Table13- 2. Categories of Accessory Behaviors.
Escape
Behaviors
Avoidance
Behaviors
Purpose Terminate block Circumvent anticipated
dis uencies
Examples Blinking, moving
head, stamping feet
Word substitutions,
stalling, using starters
Source: Based on Guitar (2006).
Emotional Reaction
Ongoing struggle in the production of speech gradu-
ally results in deep- rooted feelings of shame, frustration,
anger, anxiety, fear, negative self- perceptions, and, even-
tually, habitual avoidance of speaking situations. Young
children may already manifest strong emotional reac-
tions to their stuttering by 5years of age, or even earlier
(see Bloodstein, 1995, p. 49). Some children may stop
talking for several days or develop a habit of asking par-
ents to speak for them. Older children may avoid oral
presentations or voluntary participation in class. Adults
may avoid the telephone and begin withdrawing from
social situations. Starkweather and Givens- Ackerman
(1997, p. 34) describe a startling form of avoidance in
which individuals who stutter may “lose touch” with
their surroundings and what they are doing, presumably
to block out the pain and negative experience associated
with their stuttering.
KEY ASSESSMENT PARAMETERS
 e following sections outline key parameters to be con-
sidered in the assessment of a client who stutters.  ese
parameters form the basis for many of the formal and
informal measures designed for evaluating stuttering.
Although the availability of published protocols makes
it possible for clinicians to evaluate stuttering using
standardized materials and scoring, we hope the details
provided in this section will help clinicians understand
the basic components from which these measures are
derived, as well as the criteria used to arrive at specifi c
clinical decisions.
Certain components of stuttering disorders, such as
the presence and severity of disfl uencies, are relatively
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ASSESSMENT OF FLUENCY DISORDERS 353
FLUENCY DISORDERS
13
simple to measure and quantify. Other aspects of stut-
tering, such as the extent to which an individual may
be reacting to his or her disfl uencies, may be more dif-
fi cult to analyze. Ideally, assessment of fl uency must
examine core behaviors as well as attitudes, perceptions,
and reactions to stuttering. Following is a list of general
areas explored in most fl uency evaluations. When avail-
able, we include normative data so that clinicians can
determine whether certain behaviors are atypical or not.
Measurement of Core Behaviors
Because certain core behaviors are present in the speech
of fl uent speakers, a key clinical question is how to dif-
ferentiate typical disfl uencies from those that signify a
stuttering disorder.  is can be accomplished by looking
at specifi c characteristics of the core behaviors:
1. Disfl uency types: In the section on core behaviors
(see Table13- 1 for summary), we identifi ed
specifi c types of disfl uencies (e.g., phrase repeti-
tions, interjections) that are more likely to be
considered normal disfl uencies, and other types
(e.g., sound repetitions, prolongations, blocks,
broken words) more likely to be perceived by
listeners as atypical. Recording the types of dis-
fl uencies observed helps the clinician determine
the presence and severity of a stuttering disor-
der. A useful worksheet is provided later in the
section on core assessment procedures. Specifi c
questions to consider:
a. Are disfl uencies comprised primarily of typi-
cal disfl uencies or atypical disfl uencies?
b. What is the proportion of within- word
disfl uencies to between- word disfl uencies?
 e same question can be framed using the
terms SLDs and other disfl uencies (ODs).
How much of the total number of disfl u-
encies do the SLDs represent? Occasional
SLDs may be present in speech produced by
nonstuttering children; however, the propor-
tion of SLDs to ODs will diff er signifi cantly
between children who do and do not stutter.
According to Yairi (1997), the proportion of
SLDs to the total number of disfl uencies will
typically be 36% to 50%. Children who stut-
ter, on the other hand, tend to show an aver-
age of at least 65% SLDs.
c. What is the specifi c frequency of within-
word disfl uencies (or SLDs)? Based on data
reviewed by Yairi (1997), we know that pre-
school children who stutter produce at least
3 or 4 SLDs per 100 syllables, whereas non-
stuttering children produce fewer than
3 SLDs for the same total number of syllables.
2. Frequency of disfl uencies: Examining the amount
of disfl uency present can provide information
about the presence and severity of a stuttering
disorder and is usually measured as the number
of disfl uencies per 100 words or 100 syllables.
In general, it is preferable to use measurements
based on syllable counts in order to capture
multiple disfl uencies that may occur on multi-
syllabic words and to be able to form accurate
comparisons between disfl uency counts obtained
during the preschool years, when single- syllable
words predominate, to later years, when use of
multi- syllabic words increases.
It is well established that children who stut-
ter, as a group, produce more disfl uencies than
nonstuttering children; however, there tends to
be some degree of overlap between groups.  is
fact makes it diffi cult to diff erentiate stuttering
from normal disfl uency on the basis of frequency
alone. Nevertheless, considerable data for both
children and adults who stutter suggest that
the presence of more than 10 disfl uencies
per 100 words is valid cause for concern (Adams,
1980; Bloodstein & Bernstein Ratner, 2008;
p. 318; Yairi, 1997; Yaruss, 1998). Similar fi ndings
are reported for frequency counts that are based
on syllables rather than words. Yairi (1997), for
example, found an average of 17 disfl uencies
per 100 spoken syllables in preschool children
who stuttered, and 19–20 disfl uencies per 100
syllables in slightly younger children who were
closer to the onset of stuttering. In contrast, non-
stuttering children produced only 6–8 disfl uen-
cies for the same total number of syllables. Other
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354 CHAPTER 13
researchers (e.g., Pellowski & Conture, 2002)
focus specifi cally on SLDs and suggest that the
presence of more than 3 SLDs per 100 words
represents incipient stuttering rather than typical
developmental disfl uencies. For additional infor-
mation on counting the frequency of disfl uen-
cies, readers are referred to the sample worksheet
provided later in this chapter in the section on
assessment aims and procedures.  e worksheet
is designed for a 100- syllable speech sample;
however, clinicians can design their own tables to
accommodate any total number of syllables and
follow the instructions provided to derive the
percentage of stuttered syllables (or percentage
of stuttered words).
3. Presence of clusters: Clusters are defi ned as the
occurrence of two or more disfl uencies on the
same word or utterance (e.g., I- I- I went to
the b- b- beach). Several researchers have sug-
gested that clusters may be a useful marker
of early stuttering based on studies showing
a much greater prevalence of clusters in the
speech of stuttering children compared to that
of nonstuttering children (e.g., Hubbard &
Yairi, 1988; LaSalle & Conture, 1995; Logan &
LaSalle, 1999). According to Zembrowski
and Kelly (2002), children with three or more
clusters of disfl uencies in a 100- syllable sample
should be considered to be stuttering or “at risk”
for stuttering. Recent fi ndings by Robb and
colleagues (Robb, Sargent, & O’Beirne, 2009)
indicate that disfl uency clusters continue to be
a feature of stuttering in adults and that the
frequency of clusters is positively correlated with
the overall percentage and severity of disfl uency.
4. Duration of disfl uencies:  e duration of certain
disfl uencies, such as repetitions, can be mea-
sured as the number of reiterations (repetitions
beyond the initial production); however, the du-
ration of most other forms of disfl uency is de-
scribed as a length of time (typically in seconds).
According to Bloodstein and Bernstein- Ratner
(2008, p. 3), measurements of duration have
limited usefulness for describing the severity of
stuttering in adults, as most adults who stutter
do not vary much from each other in this partic-
ular feature. Nevertheless, duration of disfl uency
is recommended by a number of researchers
(e.g., Yairi & Lewis, 1984) for the diff erential
diagnosis of typical versus atypical disfl uency
in young children, and can be quite helpful in
clinical practice.  ese fi ndings are summarized
in Table13- 3.
Observation of Accessory Behaviors
 e presence of accessory behaviors refl ects the child’s
growing awareness of his or her stuttering and is evi-
dence of increasing struggle. Most often, accessory
behaviors emerge during the early elementary years
and gradually become part of the child’s chronic stut-
tering pattern. Some children, however, display associ-
ated behaviors as early as 1month following the onset of
stuttering (Zembrowski & Kelly, 2002). Either way, the
presence of these symptoms unequivocally diff erentiates
between typical disfl uency and stuttering, as nonstutter-
ing children do not produce secondary characteristics
when they are disfl uent. To measure these characteris-
tics, the clinician must carefully note extraneous behav-
iors that occur specifi cally during moments of disfl uency
Table13- 3. Differentiating Incipient Stuttering and Normal Dis uency Based on Duration.
DISFLUENCY Incipient Stuttering Normal Dis uency Reference
Within- word repetitions
(sound, syllable, or single-
syllable words)
More than 2 reiterations
(e.g., “b- b- b- ball”)
Fewer than 2 reiterations
(e.g., “b- ball”)
Van Riper (1982),
Adams (1980),
Curlee (1999),
Yairi & Lewis (1984)
Prolongations Longer than 1second Less than 1second
© Cengage Learning 2012
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ASSESSMENT OF FLUENCY DISORDERS 355
FLUENCY DISORDERS
13
(general movements or behaviors that are observed dur-
ing both fl uent and nonfl uent speech production, such
as nervous tics or habits, are excluded). Accessory behav-
iors may include one or more of the following:
● closing eyes
●blinking rapidly
●squeezing eyes shut
●looking around
●moving eyes vertically or laterally
●consistent loss of eye contact
●throwing head back
●torso or limb movements
●foot, hand, or fi nger tapping
●audible inhalation or exhalation
●gasping
●visible tension around face or mouth
●facial grimacing
●lip pursing or pressing
●tongue clicking
●sudden changes in vocal pitch, loudness, or quality
●word substitutions or circumlocutions
●stalling
It is important to keep in mind that stuttering can
sometimes be almost entirely covert, with no observ-
able symptoms at all. In such situations, the person
who stutters has become so adept at substituting words
and avoiding disfl uencies that he or she doesn’t actu-
ally appear to be stuttering.  is is the portion of the
“iceberg” that is completely hidden from view but that
may be a powerful negative force within the person who
stutters. In such situations, a diagnosis of stuttering may
be based on the individual’s perception of him- or her-
self as a person who stutters and the shame, anxiety,
fear, and avoidance behaviors that typically accompany
this perception. For further information related to the
evaluation of covert symptoms associated with stutter-
ing, please see the following discussion on assessment of
psychological reaction and avoidance behaviors.
Assessment of Variability
An important, and sometimes confusing, aspect of stut-
tering is the inconsistencies with which symptoms are
observed, particularly in young children. Near onset, par-
ents will often report that the child’s stuttering “comes
and goes” or that it fl uctuates in severity, depending on
a variety of factors, such as the child’s fatigue, level of
excitement, familiarity with the listener, or other specifi c
characteristics related to the setting or the nature of the
interaction. To some degree, fl uctuations in disfl uency
are typical for all individuals who stutter; however, it
is helpful to determine the extent to which the disor-
der may vary in a particular speaker and whether there
are specifi c factors or situations that precipitate greater
fl uency or disfl uency. Perhaps most critical is to estab-
lish whether the level of disfl uency observed during an
evaluation is typical for that individual. In Table13- 4,
Table13- 4. Sources and Examples of Variability.
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).
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356 CHAPTER 13
we list a number of factors associated with variability in
stuttering severity. Although it is not practical or even
desirable to measure all of these factors, we encourage
you to consider how each potential source of variability
may aff ect specifi c clients and to measure this variability
directly when appropriate.
Assessment of Psychological Reaction
and Avoidance Behaviors
Most people with chronic forms of stuttering gradu-
ally begin to try avoiding disfl uencies. Paradoxically,
the struggle to avoid stuttering only serves to inten-
sify the disorder by adding layers of accessory behav-
iors and anxiety that can become quite pervasive. Many
theories of stuttering, such as Bloodstein’s anticipa-
tory struggle hypothesis (Bloodstein, 1995, pp. 63–67),
emphasize the ways in which negative perceptions and
beliefs exacerbate and complicate stuttering disorders.
Even individuals with mild forms of stuttering may
react signifi cantly to disfl uencies, showing very negative
attitudes about their stuttering, extreme forms of self-
criticism, and hypervigilance about their speech pro-
duction (Leith, Mahr, & Miller, 1993). Gaining insight
into these beliefs and attitudes is therefore an integral
component of the diagnostic process.
Over the past several decades, many diff erent pro-
tocols have emerged to help clinicians examine diff er-
ent attitudinal and emotional reactions to stuttering.
Although there is no single instrument that provides
a comprehensive assessment of all the possible psycho-
logical sequelae of stuttering, each protocol will help
clinicians learn about specifi c ways in which a client
may perceive and feel about his or her stuttering, com-
municative abilities, and social situations in general.
Table13- 5 lists some of the broad areas considered in
these scales with sample questions that might be pre-
sented to the person who stutters, often in written form.
Typically, scales are developed by administering sets
of questions or statements to both people who stutter
and people who do not. Participants indicate whether
individual statements or questions are characteristic of
them. Comparing these responses provides the basis for
determining the profi les that contain the typical char-
acteristics associated with those who stutter. Further in
the chapter, we present references and details regarding
specifi c protocols available for clinical use.
Assessment of Locus of Control
of Behavior (LCB)
A concept closely related to attitudes and perception is
that of locus of control of behavior (LCB).  is idea was
popularized by social psychologist Julian Rotter through
his development of a published scale (1966) to measure
this construct. His original scale has since been adapted
to evaluate perceptions of control in people who stut-
ter (e.g., Locus of Control of Behavior Scale developed
by Craig, Franklin, & Andrews, 1984). Locus of control
refers to the extent to which an individual attributes the
outcome of events to external circumstances, such as luck,
coincidence, and environmental factors, versus internal
factors, such as personal abilities and eff ort. In general,
individuals who locate control outside of themselves
believe that they have less control over their fate and tend
to be more stressed and depression- prone as a result.
Numerous researchers have examined LCB in people
who stutter with somewhat equivocal fi ndings. First, it is
unclear whether people who stutter actually diff er from
nonstutterers in LCB, particularly when measuring over-
all LCB rather than locus- of- control beliefs related spe-
cifi cally to speech production (McDonough & Quesal,
1988). Moreover, LCB scores may not be associated with
treatment outcome in any predictable way (Ladouceur,
Caron, & Caron, 1989), although certain researchers
have provided evidence to the contrary (e.g., Craig &
Andrews, 1985). Nevertheless, one’s belief that he or she
is a victim of stuttering and has no control over the dis-
order is certainly an important assumption to be aware
of and to examine in fl uency assessment. Table13- 6
shows several statements and questions drawn from the
Mastery- Powerlessness S cale (Hoehn- Saric & McLeod,
1985, as cited by Leith et al., 1993). Additional protocols
for evaluating LCB in people who stutter are listed in
Table1 3- 14 later in this chapter in the section on formal
and informal assessment measures. For further infor-
mation about LCB and how the clinician can facilitate
its shift from an external to internal source, please see
Chapter2, Counseling and the Diagnostic Interview for
the Speech- Language Pathologist.
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ASSESSMENT OF FLUENCY DISORDERS 357
FLUENCY DISORDERS
13
Table13- 5. Measuring Psychological Reaction to Stuttering.
PSYCHOLOGICAL REACTION
TO STUTTERING Sample Statements and Questions
Expectancy (anticipating dif culty) • Do you help yourself get started talking by laughing, coughing, clearing your throat, or gesturing?
• Do you anticipate dif culty 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
perceptions of self as a communicator
• I usually feel that I am making a favorable impression when I speak.
• It is easy to speak with anyone.
• I socialize and mix with people easily.
• My speaking voice is pleasant.
• I have con dence 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 brie y 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 dif cult situations (e.g., have someone order food for
you in a restaurant)?
• Do you use gestures as a substitute for speaking (e.g., nodding your head instead of saying
“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).
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358 CHAPTER 13
Measurement of Speech Rate
Speech rate may refl ect the severity of an individual’s
stuttering, with severe forms of stuttering often result-
ing in signifi cant reductions in speaking and reading
rate (e.g., Bloodstein, 1995, p. 7). Very rapid speech
rates, particularly when accompanied by irregular
pacing, may also indicate the presence of a cluttering
rather than stuttering disorder. Speaking rate is typi-
cally measured as the number of either syllables or
words produced per minute, with syllable counts being
the preferred method (see earlier discussion on count-
ing the frequency of core behaviors or refer to Guitar,
2006, pp. 193–194, for more detail). All disfl uencies
are included in the speaking time total; however, extra
repetitions of phrases, words, or syllables are excluded
from the syllable count so that the fi nal syllable total
refl ects only those syllables in which meaningful infor-
mation is being conveyed to the listener. For example,
“My- my- my name is, um, Da- Da- David” would be
counted as fi ve syllables. A related measure, known as
articulatory rate, focuses specifi cally on fl uent speech.
Analysis of articulatory rate includes only syllables
that are produced fl uently, excluding all disfl uencies,
long pauses, and the time during which these occur.
Following are several suggestions (based on Guitar,
2006, p. 194; Riley, 2009) to make the task of syllable
counting as effi cient and accurate as possible:
1. Use graph paper or a table that you have pre-
pared with a predetermined number of cells;
place a dot in individual cells for each syllable or
word that is spoken.
2. Use a commercially available counter that can be
pressed rapidly for each spoken syllable or word.
3. Press a specifi c key on a standard keyboard for
each syllable spoken. (A separate key can be
used simultaneously to indicate moments of
disfl uency.)
4. Using a standard calculator, press 1! for the
fi rst syllable, then continue pressing the "
button for each subsequent syllable to keep
a running total.
5. Regardless of the counting method, a stopwatch
should be used to obtain a precise measure-
ment of the total length of time for the speech
sample. If speaking rate is being measured dur-
ing conversation, the stopwatch must be stopped
for turns taken by participants other than the
speaker of interest. To measure articulatory rate,
the stopwatch must be stopped during disfl uent
speech and during pauses so that only continu-
ous runs of fl uent speech are being considered in
the fi nal results.
Results of speaking rate calculations are interpreted
with reference to normative data reported for specifi c
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  rst: (1) look at a map and try to  gure 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 de nite 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.
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ASSESSMENT OF FLUENCY DISORDERS 359
FLUENCY DISORDERS
13
age groups and speech contexts. Tables13- 7, 13- 8, and
13- 9 list expected speaking and reading rates for fl uent
individuals based on the fi ndings of several studies.
Table13- 7. Speaking Rates for Fluent Speakers.
(syllables per minute) by Age.
AGE (YEARS) Range (spm)
3 116–163
4 117–183
5 109–183
6 140–175
8 150–180
10 165–215
12 165–220
Adults 162–230
Source: Based on Pindzola, Jenkins, & Lokken (1989) and Guitar (2006, p. 193).
Table13- 8. Range of Speaking Rates (words per minute)
in Fluent Speakers by Context.
AGE GROUP Context Range (wpm)
Children (7–11) Conversation 92–161*
Children (7–11) Narrative 87–178**
Adults Conversation 116–164
Adults Monologue 114–173
Adults Reading 148–190
Source: Based on Andrews & Ingham (1971), Shapiro (1999 pp. 395–396), and Sturm &
Seery (2007).
* Rate in wpm: 109–195.
** Rate in wpm: 100–216.
Table13- 9. Average Speaking Rates (words per minute)
for Fluent Adults by Age and Context.
AGE
Conversation
(wpm)
Monologue
(wpm)
Reading
(wpm)
21–30 182.7 151.4 219.9
45–54 153.7 133.7 182.1
55–64 168.7 141.7 190.1
Based on Duchin & Mysak (1987).
Assessment of Environmental Demands
and Expectations
Many theorists have discussed the role of the envi-
ronment in the development of stuttering disorders.
Wendell Joh nson’s or ig in al not ion that stutte ring may
begin “in the parent’s ear” has been largely discredited
(Meyers, 1986; Yairi & Lewis, 1984); however, this idea
set the stage for other hypotheses that have been more
widely accepted and that have inspired specifi c clinical
approaches to stuttering intervention. Sheehan (1970,
p. 286) believed that children who stutter have probably
had too many demands placed on them while receiving
too little support to meet those demands.  e “Demands
and Capacities” model (Starkweather & Gottwald,
1990) similarly attributes stuttering to an imbalance
between a child’s developing capacities in skill areas
required for communication and the demands, stan-
dards, or expectations imposed on the child by his or
her environment. Environmental demands may take the
form of rapid questioning, frequent interruptions, use of
overly complex sentences or vocabulary, impatience with
developmentally typical disfl uency, or high standards for
achievement and performance in general.  ese sorts of
challenges are alluded to in Marty Jezer’s (1997) book
about his own stuttering, in which he writes: “To be
heard I had to force my way into a conversation (some-
thing I rarely had the confi dence to do) and then say
what I had to say as fast as I could in order not to be
interrupted.” Interestingly, a recent longitudinal study
reported by Reilly and colleagues (2010) has identifi ed
higher levels of maternal education as a predictive factor
for the emergence of stuttering before age 3, which sug-
gests that parents’ standards may be infl uenced by their
own educational experiences and achievements and that
these standards may be either implicitly and/or explic-
itly relayed to very young children.
Environmental pressures can be evaluated by con-
sidering 7 specifi c questions on p. 14 (see Guitar, 2006,
pp. 241–242, and Starkweather & Givens- Ackerman,
1997, pp. 91–92, for further details).  ese factors are
most often discussed with relation to young children
who stutter; however, many remain relevant for older
children, adolescents, and adults.
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360 CHAPTER 13
1. What is the speaking rate of the parents or
other signifi cant speakers in the child’s environ-
ment? How do these rates compare to the rate
of the child’s speech? ( ere is no established
norm for measuring the diff erence between the
speaking rates of a child and adults in the child’s
environment; however, Zebrowski and Kelly
[2002] suggest that a diff erence of 100 syllables
per minute may be signifi cant.) Adults, too,
are aff ected by the speech rate of their listeners
and will often report more diffi culty speaking
when conversational partners use a particularly
rapid rate of speech (Starkweather & Givens-
Ackerman, 1997, pp. 91–92).
2. Do parents use overly complex sentences or dif-
fi cult vocabulary when speaking with the child?
Young children who stutter may be more likely
to persist when parents use syntax or vocabulary
that is beyond the child’s level (e.g., Kloth et al.,
1999).
3. How do parents react to the child’s disfl uency?
Are they supportive or critical? Empathetic or
anxious? For an older individual who stutters,
how do teachers, employers, or colleagues react?
4. What type of communication style is used by
the child’s family or in the adult speaker’s work-
place? Are there frequent interruptions,
or is there consistent turn- taking during
conversations?
5. What is the general atmosphere of the house-
hold? Is it typically rushed and busy, or is it
relaxed and calm? Is there a consistent daily
schedule, or is there frequent change and lack
of predictability?
6. Is the individual often in social situations that
involve signifi cant time pressure (e.g., order-
ing in a store or restaurant where customers
are waiting behind him or her, speaking to
customer- service representatives over the
telephone)?
7. Does the family have very high standards for
academic, athletic, social, or verbal performance?
Does the child feel inadequate in comparison to
his or her siblings?
Related Measures
As for most speech and language disorders, assessment
of fl uency involves not only consideration of features
related directly to stuttering but also evaluation of other
systems and abilities that contribute to the production
of speech.  ese include:
●Oral motor strength, coordination, and control:
Measures of articulatory control and diado-
chokinetic rate may help the clinician rule out
speech production diffi culties related to dys-
praxia or apraxia. Assessment of oral motor
function can also provide important information
about the speaker’s ability to control articula-
tory structures in the absence of verbal demands
(i.e., in simple speech contexts such as isolated
sounds or syllables). For more information on
this topic, please see Chapter6, Assessment of
the Oral- Peripheral Speech Mechanism.
●Receptive and expressive language skills: Just as
rapid growth in the verbal system accounts for
normal disfl uency in typically developing chil-
dren, persisting diffi culties in receptive and/or ex-
pressive language may contribute to or exacerbate
stuttering disorders (Anderson & Conture, 2000).
Diffi culties with word retrieval and sentence for-
mulation, in particular, can cause disfl uencies in
speech production (Boscolo, Bernstein Ratner, &
Rescorla, 2002), but may not represent a stutter-
ing disorder at all and would require a very dif-
ferent type of treatment approach. Additionally,
cluttering disorders often involve diffi culties in
organizing and formulating thoughts, whereas
stuttering disorders do not (Van Zaalen, Wijnen, &
De Jonckere, 2009).  e presence of defi cits
within the language system, therefore, can be an
important consideration for diff erential diagno-
sis. For a complete discussion on the evaluation
of language disorders, please refer to Chapter8,
Assessment of Preschool Language Disorders,
and Chapter10, Assessment of School- Age
Language/Literacy Disorders.
●Articulation and overall speech intelligibility:
Careful assessment of articulatory rate, accuracy,
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ASSESSMENT OF FLUENCY DISORDERS 361
FLUENCY DISORDERS
13
and intelligibility is critical for diff erential diag-
nosis of cluttering and stuttering. Rapid and/or
irregular articulatory rate is a key feature of clut-
tering, as are excessive coarticulations (deletion
of sounds or syllables in multi- syllabic words),
indistinct articulation, and reduced overall
speech intelligibility (St. Louis, Myers, Bakker,
Klass, & Raphael, 2007). Diff erential diagnosis
of stuttering and cluttering is considered in
more detail later in this chapter. Further infor-
mation on the assessment of articulation can be
found in Chapter7, Assessment of Articulation
and Phonological Disorders.
●Voice: Basic aspects of vocal function, such as
vocal intensity, pitch, and quality, should be
considered and can typically be evaluated infor-
mally using the same speech samples obtained
for fl uency analyses. Readers are referred to
Chapter12, Assessment of Voice Disorders, for
further information on this topic.
●Hearing: A basic hearing screening should be
included in all standard speech and language
evaluations. For more information, please see
Chapter5,  e Audiological Screening for the
Speech- Language Evaluation.
●Nonverbal intelligence: Assessment of intel-
ligence is not typically included in fl uency
assessment; however, higher nonverbal IQ is as-
sociated with greater likelihood of spontaneous
recovery from early stuttering (Yairi, Ambrose,
Paden, &  roneburg, 1996) and may be a
useful prognostic indicator, particularly when
evaluating preschool children.
ASSESSMENT AIMS
AND PROCEDURES
 e primary aim of assessment is usually to determine
the presence of a disorder, as well as to describe the nature
and severity of the problem prior to initiating treatment.
In addition to these goals, Shenker (2006) emphasizes
the importance of using continuous outcome measures
in order to monitor progress while a client is in therapy
and to measure maintenance of fl uency following the ter-
mination of treatment. Shenker further encourages the
establishment of self- measurement as a specifi c treatment
goal. Training clients to measure their own outcomes and
overall success can facilitate their acceptance of responsi-
bility for treatment, and help them become more active
participants in the therapeutic process.
Certain general procedures form the basis for all fl u-
ency evaluations, regardless of the client’s age:
●Case history: Before beginning any evaluation,
it is essential to obtain background information
related to prenatal and birth circumstances, fam-
ily structure, general motor and speech-language
development, academic performance, social his-
tory, medical/surgical history, and employment
information, if relevant. It is helpful to mail
paperwork to parents or clients and have them
send this information back prior to the sched-
uled evaluation so that you can form certain
expectations and prepare accordingly.
●Interview the parent and/or client:  e inter-
view provides clinicians with the opportunity
to review the case history, obtain a general
impression of the client, and explore questions
that can provide important information about
the stuttering and its eff ect on the client’s life.
Sample questions are provided later in the
chapter in the sections covering assessment
for specifi c age groups.
●Direct interaction with the child, teen, or adult in
order to obtain speech samples for further anal-
ysis:  is may be accomplished through sponta-
neous play, structured speech tasks, and/or
conversation and is discussed in more detail for
specifi c age groups later in the chapter.
●Recording speech samples: Video recording is
strongly recommended for all fl uency evalua-
tions in order to capture both core stuttering
behaviors as well as accessory behaviors, and to
ensure precise quantifi cation of these symptoms.
Signifi cant diff erences have been reported be-
tween severity ratings based on audio recordings
versus audio- visual recordings, with audio- based
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362 CHAPTER 13
ratings being much less reliable and tending to
underestimate the frequency of disfl uencies and
related symptoms (Rousseau, Onslow, Packman, &
Jones, 2008). Use of video samples can also be
an extremely eff ective way to help clients un-
derstand, monitor, and measure their stuttering
behaviors.
●Informal analysis of stuttering behaviors:
Experienced clinicians may be able to perform
real- time analysis of disfl uency counts, using
prepared charts and forms that are based on
clinic- specifi c methods.  is form of analysis
can also be completed later by reviewing re-
corded speech samples obtained during the
evaluation. Examples and details related to
such methods can be found in Yaruss (1998).
Following is a sample form to demonstrate
analysis of disfl uencies in 100 syllables.
100- syllable sample: Place a dot in one box for each
fl uent syllable or word spoken. Use the following abbre-
viations to indicate disfl uencies. (Multiple reiterations
of the same disfl uency can be noted, e.g., by placing a
superscript above the symbol, such as R- p2, but should
not be indicated by multiple abbreviations in separate
boxes.):
R- w ••••B•B••
•R- sy ••B•••••
•••••R- pP •••
••P••••R- sd •R- w
•••• I•••••
R- sd ••P•• I•••
•B•••••••R- p
••••B••R••
•P••••••••
••P••R- w ••P•
R- p (phrase repetition) P (prolongation)
R- w (whole- word repetition) B (block)
R- sy (syllable repetition) I (interjection)
R- sd (sound repetition) R (revision)
Results can then be organized to refl ect the fre-
quency of each disfl uency type and relative proportion
of within- word to between- word disfl uencies.
Within- Word
Dis uencies
Between- Word
Dis uencies
Word repetitions
(single syllable):
3 Phrase repetitions: 2
Syllable repetitions: 1 Word repetitions
(multi- syllabic):
0
Sound repetitions: 2 Revisions: 0
Prolongations: 6 Interjections: 2
Blocks: 5
Total within- word
dis uencies:
17 Total between- word
dis uencies:
4
Informal analyses may also involve computing
speaking rate, percent of stuttered syllables, and spe-
cifi c proportions represented by each type of disfl uency.
 ese calculations will require the use of a stopwatch,
as well as some method for counting syllables and time
(in seconds), as discussed earlier in the sections on
counting frequency of disfl uencies and the section on
measuring speaking rate. Use of an Excel spreadsheet
with basic formulas may simplify the task of deriving
an overall percentage of syllables stuttered (%SS) as
well as individual frequencies (expressed in %SS) for
each disfl uency type and disfl uency category (within-
vs. between- word), which may be required for certain
assessment protocols. A sample table may be organized
as follows:
●Use of formal and informal assessment mea-
sures to quantify symptoms and rate stuttering
severity: Many scales and protocols have been
published to measure specifi c aspects of stutter-
ing behavior, describe psychological reactions
to stuttering, and predict stuttering chronicity.
 ese are listed and described in further detail
later in this chapter in the section “Formal and
Informal Assessment Measures for Stuttering
Disorders on p. 25.”
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ASSESSMENT OF FLUENCY DISORDERS 363
FLUENCY DISORDERS
13
●Stimulability testing: An important part of the
assessment process is determining the client’s
responsiveness to specifi c treatment techniques
that are demonstrated by the clinician. A com-
plete discussion on the various forms of treat-
ment available for stuttering is beyond the scope
of this chapter; however, the evaluation should
involve brief trials of strategies such as easy on-
sets, continuous phonation, or pull- outs for older
children and adults; and slow, relaxed forms of
speaking for young children. Clients may express
a preference for certain methods over others, may
be able to imitate certain techniques more easily
than others, or may be able to imitate techniques
only in specifi c speech contexts (e.g., single words
beginning with vowels).  ese considerations are
essential for eff ectively bridging assessment fi nd-
ings to practical treatment planning.
Remaining sections in this chapter are subdivided by
age group because stuttering disorders tend to evolve in
fairly predictable ways over the course of development.
Dis uency type Total Within Between %SS
BETWEEN- WORD
Phrase repetition 0 0 0
Word repetition
(multisyllabic)
5 5 1.67
Interjections 2 2 0.67
Running start 3 3 1
Revision 1 1 0.33
WITHIN- WORD
Word repetition
(single syllable)
6 6 2
Syllable repetition 4 4 1.33
Sound repetition 5 5 1.67
Sound
prolongation
3 3 1
Block 5 5 1.67
Broken word 0 0 0
Totals 34 23 11 11.33
Category % 67.65 32.35
% SS 11.33 7.67 3.67
Syllable number 300
As a child with stuttering matures, we see changes in
the specifi c types of disfl uencies that predominate, as
well as emergence of physical tension and accessory
behaviors; development of negative attitudes, emotions,
and self- perceptions; and, often, an increasing assort-
ment of avoidance behaviors and situational fears (see
Guitar, 2006, pp. 137–169, for details on the develop-
ment of stuttering disorder).  e assessment process
varies somewhat based on the individual’s age and the
level to which his or her stuttering has progressed.
ASSESSMENT
OF PRESCHOOL CHILDREN
 e evaluation of stuttering in preschool children is
driven by two key questions: (1) Is this child stuttering—
that is, are the child’s disfl uencies developmentally typi-
cal or do they represent a stuttering disorder? (2) If the
child is stuttering, is the disorder likely to be outgrown
naturally, or is it more likely to persist?
 e clinician will typically begin by interviewing the
child’s parent(s) or guardian and reviewing background
information provided. During this interaction, the cli-
nician may seek answers to specifi c questions regarding
the nature and history of the fl uency disorder but should
also be prepared to listen, answer questions, and provide
information. Open- ended questions are generally the
most eff ective means of learning about the child, the
child’s environment, and the stuttering problem. Initial
questions may consist of the following:
●Tell me about your child’s speech; what are your
concerns?
●Describe your pregnancy with this child. Were
there any complications during the birth?
●How would you describe this child’s motor
development?
●What was the child’s early speech and language
development like? Does the child have any diffi -
culties producing specifi c sounds, understanding
what others are saying to him or her, or express-
ing him- or herself?
●Is there any family history of stuttering or other
speech-language problems?
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364 CHAPTER 13
Additional inquiries may focus more specifi cally on
the child’s disfl uencies:
●How does the stuttering sound? Can you de-
scribe or demonstrate it?
●When were disfl uencies fi rst noted? How did
the disfl uencies sound at that time? Have the
disfl uencies changed since then?
●Was anything unusual occurring in the child’s
life at the time of onset? Was anything going on
in the family or at school?
●Does the child seem aware of his or her stutter-
ing in any way? If so, how does he or she react?
●Does the child ever avoid speaking due to dis-
fl uencies? Does the child ask others to speak for
him or her, and say “forget it,” or change a word
when it is diffi cult?
●Describe the child’s personality: Is he or she
sensitive, anxious, timid, and introverted, or
more self- confi dent, resilient, and outgoing?
●What is the family structure? Are there siblings?
How does the child relate to them?
●What is the child’s schedule like? Are there
situations or settings that seem to make the
stuttering worse or better?
●What is the atmosphere like at home? Is it fast-
paced, stressful, or noisy? Are there often several
people talking at once?
●Do the parents have ideas about what caused
the problem?
●How do the parents typically react to the child’s
stuttering— what do they say or do?
●Has the child been evaluated or treated? What
advice were the parents given? What was the
nature of the intervention?
Responses to these questions will guide the clini-
cian’s decisions throughout the rest of the diagnos-
tic process. If the child’s fl uency is highly variable or
the child is described as sensitive and shy, the clini-
cian may have parents record multiple speech samples
outside of the clinic to supplement the one obtained
during assessment. Details about the child’s family and
home environment may indicate the need for more
direct observations of these interactions and for specifi c
management recommendations. Reported concerns about
speech and language development would clearly indicate
the need for more in- depth assessment of these skill areas
and the ways in which language diffi culties may be inter-
fering with the child’s ability to express him- or herself
fl uently. Finally, reports of emotional trauma, motor dif-
fi culties, or academic problems may indicate the need
for referrals to other professionals in order to clarify the
nature of the fl uency disorder and its potential causes.
To evaluate fl uency in young children, clinicians
typically arrange two types of interactions: one in which
the clinician observes parents or guardians interacting
with the child, and one in which the clinician interacts
with the child directly. Parent–child interaction involves
10–15 minutes of natural play or conversation and pro-
vides an opportunity for the clinician to observe whether
there are specifi c communicative behaviors contributing
to the child’s disfl uencies.  ese may include:
●frequent interruptions
●high proportion of questions versus comments
●use of rapid speaking rate
●use of complex vocabulary
●use of lengthy and/or syntactically complex
sentences
●asking a second question before the initial one
was answered
●poor turn- taking
●frequent correction of child’s behavior (verbal/
nonverbal)
●fi lling in words or fi nishing the child’s sentences
 e primary aim of the clinician’s interaction with
the child is to obtain a representative speech sample.
 is may be accomplished through one or more of the
following tasks:
●spontaneous speaking during play (e.g., blocks,
play fi gures, dolls, play dough)
●describing pictures scenes
●telling a story based on a wordless picture book
●narrating a recent event or familiar story
●play with pressure: the clinician interrupts,
speaks rapidly, challenges or disagrees with the
child, and imposes pressure to induce disfl uen-
cies (see Gregory & Hill, 1999, for further detail)
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ASSESSMENT OF FLUENCY DISORDERS 365
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13
Although speech samples of 300 words or syllables
are often considered adequate for fl uency analysis
(e.g., Riley, 2009), it is recommended that clinicians
record longer speech samples (e.g., 600 syllables)
for preschool- age children, particularly when
the child is demonstrating relatively low levels of dis-
fl uency, as the additional information can be criti-
cal for correct diagnosis. As demonstrated by Sawyer
and Yairi (2006), the frequency of SLDs tends to
increase for most children as sample sizes become
longer, and a diagnosis of stuttering may be missed
when only 300 syllables are considered. According to
Curlee (1999), the use of word counts is satisfactory
for 2- to 3- year- old children because words produced
by young children generally do not consist of many
syllables; however, syllable measures are preferred
for children who use a greater percentage (more
than 25%) of multi- syllabic words. Another impor-
tant factor to consider is the great deal of variability
typically present in the stuttering of young children.
Obtaining several speech samples in diff erent settings
(e.g., home, preschool, clinic), with diff erent speakers
(e.g., mother, father, clinician), and during diff erent
activities (e.g., spontaneous play, picture description,
play with pressure) often provides the best represen-
tation of the child’s typical speaking pattern as well
as important information about environmental infl u-
ences on the child’s fl uency levels.
Once speech samples are obtained and key assess-
ment parameters have been analyzed, these results can
be used by the clinician to determine the presence of a
stuttering disorder, the severity of the disorder, and its
likelihood to persist. Numerous general criteria are pro-
vided in the literature in addition to various formal and
informal protocols to help clinicians with these deci-
sions. Following are several examples of these criteria as
well as an overview of the scales and protocols that are
available for this age group.
According to Guitar (2006, pp. 138–156), young
children’s disfl uencies can be classifi ed as developmen-
tally normal, borderline stuttering, or beginning stutter-
ing based on the characteristics shown in Table13- 10.
Curlee (1999) further describes fi ve potential diag-
nostic conclusions that may be reached as a result of
the young child’s fl uency assessment.  ese profi les
(as shown in Table13- 11) may help clinicians integrate
various observations and information from the evalua-
tion in order to form specifi c recommendations.
Specifi c results of the child’s speech sample analysis
are also used to complete available protocols that can
provide information regarding the severity level of the
disfl uency and the likelihood that stuttering will persist.
A full list of measures used for preschool children and
details regarding each measure can be found later in this
chapter in the section on formal and informal assess-
ment measures for stuttering disorders. Perhaps the
Table13- 10. Classi cation of Dis uencies as Normal, Borderline, or Beginning Stuttering.
NORMAL DISFLUENCY Borderline Stuttering Beginning Stuttering
• Fewer than 10 dis uencies per 100 words
• Dis uencies consist primarily of non- SLDs
• Repetitions consist of 2 or fewer reiterations
• Repetitions are slow and regular in tempo
• SLDs comprise less than 50% of the
total dis uencies
• More than 10 dis uencies
per 100 words
• Loose, relaxed dis uencies
• SLDs and non- SLDs may be present
• Repetitions may have
more than 2 reiterations
• More than 50% of dis uencies
are SLDs
• Clusters may be present
• Dis uencies are marked by tension
• Repetitions are rapid and rushed
• Rises in pitch during repetitions
and prolongations
• Struggle with air ow or phonation
• Facial tension
• Awareness, possible frustration
• May use escape behaviors to terminate
blocks (e.g., eye blink)
• Possible avoidance (e.g., word substitution)
Source: Based on Guitar (2006, pp. 138–156).
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366 CHAPTER 13
most commonly used protocol is the Stuttering Severity
Instrument–4 (SSI- 4), recently revised by Riley (2009),
which provides percentile scores and severity ratings
(mild, very mild, moderate, severe, very severe) based on
the frequency and duration of core behaviors as well as
the presence and nature of associated behaviors. When
used for older children or adults, the SSI- 4 combines
samples obtained in both speaking and reading tasks;
however, normative data is also provided for nonreaders.
 e Pindzola Protocol for Diff erentiating the Incipient
Stutterer (Pindzola & White, 1986) can help the clini-
cian determine whether a child’s disfl uencies are devel-
opmentally typical or more consistent with childhood
stuttering based on specifi c speech characteristics, such
as disfl uency type, frequency, duration, and the presence
of associated behaviors or avoidances.  e Stuttering
Prediction Instrument for Young Children (Riley, 1981)
is a formal measure that provides prognostic informa-
tion about the likelihood of spontaneous recovery.  e
Behavioral Style Questionnaire (McDevitt & Carey,
1978) is a set of questions administered to parents in
order to obtain information about the child’s person-
ality. Although this measure does not assess stutter-
ing behaviors directly, it can help the clinician identify
temperamental traits, such as inhibition and sensitivity,
that may contribute to the development of stuttering
Table13- 11. Dis uency Pro les and Diagnostic Conclusions.
DISFLUENCY PROFILE Conclusion Recommendation
• May be highly dis uent but SLD frequency falls below
2%–3% of total words or syllables
Minimal/no signs of childhood
stuttering
No intervention or ongoing follow- up needed;
re assess with any signi cant change
• No excessive muscle tension or effort
• Normal speech and language skills
• Initial stuttering described as severe; however,
few SLDs present in sample
Inconsistent signs of childhood
stuttering
Further observation and testing; ensure that
low frequency of dis uency during evalua-
tion represents child’s typical  uency level
• SLDs on 3%–10% of total syllables/words Signs of childhood stuttering
present but for less than 1 year
Regular follow- up and monitoring of  uency
for 1 year post- onset; direct intervention
if no reduction in symptoms over this time
• Accessory behaviors may be present
• Evidence of muscle tension during dis uencies
• Emerging awareness of stuttering; may seem frus-
trated when having unusual dif culty
• Symptoms present less than 1 year
• Early signs of stuttering along with possible articula-
tory, phonological, and/or language disorder
Evidence of childhood stutter-
ing as well as speech and/or
language problem
Direct intervention addressing both
disorders
• Frequent dis uencies with SLDs present on 15% or
more of total syllables/words
Consistent evidence of childhood
stuttering for 1 year or longer
Immediate intervention
• Tense, effortful dis uencies
• Associated behaviors (e.g., lip tremor, blinking)
• Frustration, avoidance
• Symptoms present for 1 year or more
Source: Based on Curlee (1999).
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ASSESSMENT OF FLUENCY DISORDERS 367
FLUENCY DISORDERS
13
in young children (see Guitar, 2006, pp. 122–132, for
further detail).
Numerous factors have been associated with greater
likelihood of either chronic stuttering or natural recov-
ery (e.g., Brosch, Haege, Kalehne, & Johannsen; Curlee,
1999; Kloth et al., 1999; Rommel, Hage, Kalehne, &
Johannsen, 2000; Yairi et al., 1996; Yairi & Ambrose,
1999).  ese should be carefully considered by the clini-
cian and are outlined in Table13- 12.
ASSESSMENT
OF SCHOOL- AGE CHILDREN
Assessment of the school- age child includes most of
the same procedures used for the preschool child, with
several considerations and modifi cations. First, it is
important to remember that disfl uencies at this stage
in development are no longer likely to be spontaneously
outgrown (Guitar, 2006, p. 246).  e key questions
guiding the evaluation are therefore: (1) Is this child
stuttering? (2) If so, what is the nature and severity of
the stuttering? (3) To what extent is the child aff ected
by or reacting to his or her stuttering? (4) What forms
of treatment may be most appropriate?
For this age group, information about the stuttering
can be obtained not only from the child’s parents but
also from the child him- or herself and, if possible, from
classroom teachers. As with most interviews of this
nature, open- ended questions are often most eff ective,
with more specifi c inquiries as necessary.  e following
questions are provided as guidelines.
Child Interview
●Do you fi nd it diffi cult to speak? What usually
happens?
●How often does this happen? Does your speech
usually sound the same or does it sound diff er-
ent at diff erent times?
●Is it more diffi cult to speak in certain situations
than in others?
●Are certain words or sounds more diffi cult than
others?
●Do you ever avoid speaking because of the way
you sound?
Table13- 12. Factors Associated with Persistent Stuttering versus Spontaneous Recovery.
Associated with Persisting
Stuttering
Associated with Spontaneous
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 dif culties 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 dis uencies Dis uencies present 1 year or longer Dis uencies present less than 1 year
Changes in dis uencies No change in SLDs or worsening SLDs 1 year
post- onset
Decreased SLDs within 12–15 months
post- onset
Escape/avoidance behaviors Presence of accessory behaviors, tension, struggle,
word substitutions
No accessory behaviors, tension, struggle, or
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.
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368 CHAPTER 13
●How do other people react to your speech?
●How does your speech make you feel?
●Do you use any “tricks” to get hard words out?
Parent Interview
●How is your child doing academically? Socially?
●Does your child avoid any speaking situations
because of his or her stuttering?
●Does he or she feel ashamed? Is he or she being
teased?
●Has your child learned any strategies to manage
his or her stuttering?
Teacher Interview
●Does the child participate in class?
●Is he or she teased by classmates?
●How do you typically react to the child’s
disfl uencies?
Unlike preschoolers, school- age children are able
to provide samples of their speech in both speaking
and reading tasks, and separate analyses of stuttering
behaviors and speech rates are completed for each con-
text. Speaking tasks for this age group should include
both monologue (e.g., retelling a book/movie, describ-
ing recent events, describing sequenced picture cards)
and dialogue. Reading samples are based on reading
material below the child’s reading level to ensure that
disfl uencies are due to stuttering rather than decoding
diffi culties.  e SSI- 4 (Riley, 2009) includes reading
samples at the third- , fi fth- , and seventh- grade levels
that can be used for this purpose. Additional measures
for determining the presence and severity of stuttering
in school- age children can be found in Table13- 13 and
in the following section on formal and informal assess-
ment measures for stuttering disorders.
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
Experience of Stuttering–School
Age (OASES- S)
Yaruss, Coleman, & Quesal (2010) 7–12 Perception of stuttering; reactions
to stuttering; impact of stuttering
on communication and quality of life
A- 19 Scale for Children Who Stutter Andre & Guitar, 2006
(cited and available in Guitar, 2006)
School age Attitudes about communication
Behavioral Style Questionnaire (BSQ) McDevitt & Carey (1978) 3–7 Temperamental characteristics in
children (based on parent report)
Behavior Assessment Battery (BAB):
combination of Behavior Checklist,
Communication Attitude Test, and
Speech Situation Checklist
Vanryckeghem & Brutten (2007a);
available through Plural Publishing
6–15 Anxiety ratings for different situa-
tions; coping responses for dealing
with dis uencies; attitudes toward
communication
The Behavior Checklist (BCL) Vanryckeghem & Brutten (2007a); avail-
able through Plural Publishing (part of BAB)
School age Coping responses of the child
CALMS Rating Scale for School- Age
Children Who Stutter
Healey, Scott-Trautman, & Susca (2004) School age Cognitive, affective, linguistic,
motor, and social (CALMS) factors
Communication Attitude Test (CAT) Brutten & Dunham (1989); revised version
by Vanryckeghem & Brutten (2007a); avail-
able through Plural Publishing (part of BAB)
School age Speech- related attitudes
Communication Attitude Test
for Preschool and Kindergarten
Children Who Stutter (KiddyCAT)
Vanryckeghem & Brutten (2007b); avail-
able through Plural Publishing
Preschool
and kindergar-
ten children
Communication attitudes
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ASSESSMENT OF FLUENCY DISORDERS 369
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13
Although some information about the child’s atti-
tudes and feelings may emerge from the case history,
interview, and speaking tasks, the clinician may want
to measure this aspect of stuttering more directly using
paper- and- pencil tasks. Various measures have been
developed to assess children’s perceptions of their stut-
tering, psychological reaction to stuttering, and avoid-
ance behaviors. Most are developed based on responses
that have been found to diff erentiate children who stut-
ter from fl uent peers (e.g., De Nil & Brutten, 1991)
and provide normative data for each group. Several
sample measures for this age group include the A- 19
Scale (Guitar & Andre, as cited in Guitar, 2006), the
Communication Attitude Test (CAT; Brutten &
Dunham, 1989; revised by Vanryckeghem & Brutten,
2007b), and the Overall Assessment of the Speaker’s
Experience of Stuttering–School- Age (OASES- S)
(Yaruss, Coleman, & Quesal, 2010). A full list of avail-
able protocols for measuring attitude, perceptions, and
LCB in school- age children is provided in the following
section on formal and informal assessment measures.
Reports from teachers can also be useful in determining
a child’s reactions to stuttering and possible avoidance
behaviors. Information can be obtained through tele-
phone conferences, meetings, or through written scales
and forms, such as the Teachers Assessment of Student
Communicative Competence (Smith, McCauley, &
Guitar, 2000), in which teachers rate the child’s com-
municative functioning in the classroom.
As for preschool children, stimulability testing is
an important part of the evaluation for this age group.
Brief trials of stuttering modifi cation techniques and
simple fl uency shaping strategies can be attempted to
determine which treatment approach may be better
suited for a particular child.
ASSESSMENT OF ADOLESCENTS
AND ADULTS
Adolescents and adults with stuttering disorders typically
have an extensive history of stuttering; the key diagnos-
tic questions for individuals in this age group are usually
not concerned with whether a stuttering disorder exists,
but rather: (1) What is the nature and severity of this
individual’s stuttering? (2) How severely is this individual
MEASURE/SCALE Author/Publisher Age Behaviors Assessed
The Cooper Chronicity Prediction
Checklist
Cooper & Cooper (1985) Preschool Predicts children who will recover
with and without treatment
Crowe’s Protocols Crowe, DiLollo, & Crowe (2000) Children,
adolescents,
adults
Affective, behavioral, and cognitive
aspects of stuttering; stuttering
severity; stimulability
Pindzola Protocol for Differentiating
the Incipient Stutterer
Pindzola & White (1986) Preschool Frequency, type, and duration
of dis uency; 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
(SSC- ER and SSC- SD)
Vanryckeghem & Brutten (2007a); avail-
able through Plural Publishing (part of BAB)
School age Emotional reactions to dis uencies
Stuttering Prediction Instrument
for Young Children (SPI)
Riley (1981); published by Pro- Ed 3–8 Core stuttering behaviors and
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 dis uen-
cies; physical concomitants
© Cengage Learning 2012
Table13- 13. (Continued)
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370 CHAPTER 13
reacting to his or her stuttering? (3) What specifi c fears
or avoidance behaviors are present? (4) How has stutter-
ing aff ected and limited this individual’s life?
As mentioned earlier in this chapter, ongoing struggle
to produce speech often creates many layers of negative
emotions.  ese may be quite pervasive in the adoles-
cent or adult who stutters but diffi cult to observe and
measure. Although pretreatment measures of stuttering
severity may ultimately be the most reliable predictor
of treatment outcome (see Block, Onslow, Packman, &
Dacakis, 2006), the development of learned helplessness
and confi rmed self- perception as a poor communicator
can be serious impediments to successful fl uency inter-
vention and must be explored during an initial evalua-
tion. Sometimes, experienced stutterers may negotiate
anticipated disfl uencies so skillfully that core behaviors
will not be observed at all and assessment will need to
tap into hidden emotions, attitudes, and fears in order
to uncover any evidence of a stuttering disorder.
Interview questions for the adult who stutters will be
similar to those presented for younger populations, but
rather than focusing primarily on the “tip of the iceberg”
(that is, observable speech disfl uencies), they will place
equal emphasis on aspects of the disorder that lie beneath
the surface. Following are suggested areas of inquiry:
●When did your stuttering start? How has it
changed since then?
●How does your stuttering feel, physically and
emotionally?
●How do diff erent situations and/or listeners af-
fect your stuttering?
●Do you have specifi c “tricks” that you use to get
out of diffi cult blocks?
●Have you had prior therapy? Describe these
treatment experiences. Are there any specifi c
strategies or techniques that have been helpful?
●Do you avoid speaking or social situations? Has
your stuttering contributed to certain decisions
that you have made in your life (e.g., relation-
ships, career choices)?
●What do you aim to achieve in therapy? What
is your primary goal?
●Why have you decided to pursue treatment now?
As described for preschool and school- aged chil-
dren, the clinician can use a combination of formal and
informal measures to describe the nature and severity
of an adult’s stuttering disorder. Assessment procedures
must include tasks to measure the frequency, dura-
tion, and types of disfl uencies present in monologue,
dialogue, and reading contexts, along with qualitative
measurement of associated behaviors and calculation
of speech rate. Results of these analyses can be used to
complete a protocol such as the SSI- 4, which will pro-
vide diagnostic information about stuttering severity.
Of equal importance, however, will be the inclusion
of measures that provide information about other
aspects of the stuttering disorder.  e Perceptions of
Stuttering Inventory (PSI; Woolf, 1967), for example,
may help the clinician understand the extent of strug-
gle perceived by the client who stutters, the client’s
anticipation of failure during attempts to speak, and
the extent to which he or she avoids speaking situa-
tions.  e Modifi ed Scale of Communication Attitude
(S- 24) developed by Andrews and Cutler (1974) and
the Communication Attitude Test for Adults (BigCAT)
by Brutten and Vanryckeghem (2003) both refl ect the
client’s perceptions of him- or herself as a communi-
cator, and his or her attitude toward communication in
general. Locus of control measures, such as the Locus
of Control of Behavior (LOC- B) developed by Craig
et al. (1984) or the Speech Locus of Control Scale
(Sp- LOC) by McDonough and Quesal (1988), provide
specifi c information about whether the client views life
circumstances as the result of external forces or inter-
nal control. Understanding the way an individual views
events or approaches change, can be essential in design-
ing and planning appropriate stuttering intervention.
Numerous more recent protocols explore stuttering dis-
orders from a more holistic perspective.  ese protocols
provide measures of core behaviors as well as information
about the ways in which an individual may be reacting
to his or her stuttering and the overall impact of stut-
tering on the individual’s life. Examples of such mea-
sures include Yaruss and Quesal’s Overall Assessment
of the Speaker’s Experience of Stuttering (OASES) for
Te en ag e rs a n d Ad u lt s ( 20 10 ) an d t he Wr ig ht an d Ay re
Stuttering Self- Rating Profi le (WASSP; 2000).
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ASSESSMENT OF FLUENCY DISORDERS 371
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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):
combination of Behavior Checklist for
Adults, Adult Communication Attitude Test
(BigCAT), and Speech Situation Checklist
for Adults
Brutten &
Vanryckeghem
(2003)*
Adults Anxiety ratings for different situations; cop-
ing responses for dealing with dis uencies;
attitudes toward communication
Behavior Assessment Battery (BAB):
combination of Behavior Checklist,
Communication Attitude Test, and Speech
Situation Checklist
Vanryckeghem &
Brutten (2007a);
available through
Plural Publishing
6–15 Anxiety ratings for different situations; cop-
ing responses for dealing with dis uencies;
attitudes toward communication
Behavior Checklist for Adults (BCL) Brutten &
Vanryckeghem
(2003)*
Adults Coping responses
Communication Attitude Test for Adults
(BigCAT)
Brutten &
Vanryckeghem
(2003)*
Adults Speech- related attitudes
Crowe’s Protocols Crowe, DiLollo, &
Crowe (2000)
Children,
adolescents,
adults
Affective, behavioral, and cognitive
aspects of stuttering; stuttering severity;
stimulability
Locus of Control and Behavior (LOC- B) Craig, Franklin, &
Andrews (1984)
Older children,
adolescents,
and adults
Extent to which a person perceives
outcome of events to be under internal
or external locus of control
Modi ed Scale of Communication Attitudes
(S- 24)
Andrews &
Cutler (1974)
Adolescents
and adults
Feelings, attitudes, and self- esteem
Overall Assessment of the Speaker’s
Experience of Stuttering–Teenager
(OASES- T)
Yaruss, Quesal, &
Coleman (2010)
Adolescents
(12–17)
Perception of stuttering; reactions to
stuttering; impact of stuttering on communi-
cation and quality of life
Overall Assessment of the Speaker’s
Experience of Stuttering–Adult (OASES- A)
Yaruss & Quesal
(2010)
Adults Perception of stuttering; reactions to stut-
tering; impact of stuttering on communica-
tion and quality of life
(Continues)
Stimulability testing for adolescents and adults
can provide insight into the client’s level of behav-
ioral self- awareness, that is, the client’s ability to iden-
tify moments of disfl uency or anticipated moments of
disfl uency. Poor performance may suggest the need to
heighten the client’s attention to the physical sensa-
tions associated with stuttering in order to eventually
help him or her control disfl uencies through stuttering
modifi cation techniques. Reluctance or refusal to par-
ticipate in such tasks may indicate the need to focus on
desensitization in therapy or to consider initiating treat-
ment with a fl uency- shaping approach. In general, trial
techniques drawn from diff erent treatment approaches
can help guide the clinician in planning intervention
that will be most appropriate for the individual client to
most likely succeed.
FORMAL AND INFORMAL
ASSESSMENT MEASURES
FOR STUTTERING DISORDERS
Informal and formal assessment measures for stuttering
disorders are described in Tables13- 13 and 13- 14.
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372 CHAPTER 13
MEASURE/SCALE Author/Publisher Age Range Behaviors Assessed
Perceptions of Stuttering Inventory Woolf (1967) Adolescents
and adults
Speaker’s perception of the struggle,
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
for Adults (SSC- ER and SSC- SD)
Brutten &
Vanryckeghem
(2003)*
Adults Emotional reactions to dis uencies
Stuttering Problem Pro le Silverman (1980) Adults Identi es behaviors to be modi ed in
therapy
Stuttering Severity Instrument–4 Riley (2009); pub-
lished by Pro- Ed
2;10–adult Frequency and duration of dis uencies;
physical concomitants
Stuttering Severity Scale Lanyon (1967) Adults Severity of stuttering behaviors; attitudes
and feelings
Subjective Screening of Stuttering (SSS) Riley, Riley, & Magu-
ire (2004)
Adults Stuttering severity; locus of control;
avoidances
Unhelpful Thoughts and Beliefs
about Stuttering (UTBAS)
St. Clare, Menzies,
Onslow, Packman,
Thompson, & Block
(2009)
Adults Speech- related social anxiety
Wright and Ayre Stuttering Self- Rating
Pro le (WASSP)
Wright & Ayre (2000) 18–adult (14–18 with
clinical judgment)
Speaker’s perceptions of stuttering
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.
Table13- 14. (Continued).
DIFFERENTIAL DIAGNOSIS
OF STUTTERING AND CLUTTERING
In this fi nal section, we briefl y consider the diff eren-
tial diagnosis of stuttering and a closely related fl u-
ency disorder, cluttering. Detailed information related
to the assessment of cluttering is beyond the scope of
this work; however, numerous books, websites, and
journal publications on this topic are listed at the end
of this chapter. Cluttering is classifi ed as a disorder of
fl uency but is distinct from stuttering based on certain
key features that include: (1) abnormal fl uency that is
not consistent with stuttering, (2) rapid and/or irregu-
lar speech rate, (3) disorganized language formulation,
(4) excessive coarticulation and reduced speech intel-
ligibility, and (4) poor self- monitoring (St. Louis &
Myers, 1997). An important diff erence between the two
disorders is that stuttering consists primarily of atypi-
cal forms of disfl uency, such as prolongations or blocks,
whereas cluttering involves typical disfl uencies such as
interjections, revisions, or phrase repetitions that usu-
ally occur without visible struggle or tension (Guitar,
2006, p. 445). According to Daly and Burnett (1999),
individuals with cluttering may present with diffi -
culty in fi ve communicative dimensions: (1) cognitive,
(2) linguistic, (3) pragmatic, (4) speech, and (5) motor
abilities. Several possible impairments in each dimen-
sion are listed in Table13- 15.
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ASSESSMENT OF FLUENCY DISORDERS 373
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13
 e Predictive Cluttering Inventory (PCI), originally
developed by Daly and Cantrell (2006) and recently
revised (Van Zaalen et al., 2009), may be helpful for
identifying symptoms associated with cluttering; how-
ever, it is not a very reliable or sensitive measure in its
current form (Van Zaalen et al., 2009). In Table13- 16,
we compare characteristics of stuttering and cluttering
to assist clinicians in this diff erential diagnosis.
SUMMARY
 is chapter began with an allusion to Sheehan’s well-
known comparison of observable stuttering symptoms
to the “tip of an iceberg.” We hope that the details
provided in this chapter will help clinicians explore
beneath this surface and feel comfortable measur-
ing and interpreting not only core behaviors but also
Table13- 15. Communicative Dimensions Affected in Cluttering Disorders.
COGNITION Language Pragmatics Speech Motor
• Poor self-monitoring
• Impulsivity
• Memory dif culties
• Poor attention span
• Dif culty organizing
thoughts
• Sentence fragments
• Oral and written
language dif culty
• Dif culty listening and/
or following directions
• Inappropriate turn- taking
• Verbose or tangential
• Poor eye contact
• Inappropriate introduc-
tion or maintenance of
conversational topics
• Excessive repetitions
of words and phrases
• Omission of sounds or
syllables
• Syllable transpositions
• Prosody problems
• Poor penmanship
• General clumsiness,
poor coordination
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
Dis uencies Excessive normal dis uencies (between- word) Atypical dis uencies (primarily within- word)
Awareness/concern Frequently unaware of problem Highly aware, frustrated, and embarrassed
Articulation Slurred, imprecise No articulation dif culty
Reaction to pressure Improved performance under pressure or on demand Poorer performance under pressure
Language skills Disorganized discourse, word-  nding dif culties,
grammatical errors
Language skills generally age- appropriate
Written expression Disorganized, parallels verbal expression Normal writing skills
Attention More frequent diagnosis of attention de cit Attention de cits less frequent
Pragmatic skills Impatient listening, dif culty processing nonverbal
cues, poor conversational skills
No pragmatic de cits
Associated behaviors Generally absent Generally present
Tension/struggle Generally absent Generally present
Avoidance behaviors Generally absent Generally present
Source: Based on Daly & Burnett (1999) and Guitar (2006, pp. 451–452).
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374 CHAPTER 13
underlying perceptions, attitudes, and beliefs in the per-
son who stutters.  is chapter also illustrated the need
for broadening the diagnostic scope in order to consider
how various environmental features may contribute
to a stuttering disorder. Approaching the assessment
process from this more holistic perspective will enable
the clinician to appreciate the complex interactions
that ultimately determine the way a stuttering disor-
der is manifested in a particular individual. Specifi c age
groups were considered individually, based on certain
patterns in the way stuttering develops and evolves over
time, as well as important diff erences in the diagnostic
questions relevant for each age group. In line with this
general structure, we next present a case history and
model report for each of the age groups discussed in
order to demonstrate and apply some of the key con-
cepts reviewed in this chapter.
CASE HISTORY
AND MODEL REPORTS
Writing Rubric for Sample Reports
 e following guidelines may be useful in preparing the
Fluency section of a diagnostic report:
1. Describe the specifi c contexts in which speech
samples were obtained (e.g., play interaction
with parent, play with pressure, monologue, dia-
logue, reading, etc.).
2. Provide a summary of informal analyses that
includes: total number of syllables in sample;
speech rate; total frequency of disfl uencies (typi-
cally expressed as a percent of total syllables or
words); frequencies or relative proportions of
between- word and within- word disfl uencies;
list of disfl uency types observed with examples
for each; average duration of longest disfl uen-
cies (number of reiterations and/or in seconds);
occurrence of clusters; and presence or absence
of accessory behaviors. For example, “Informal
analyses were based on speech samples obtained
during monologue, dialogue, and reading, with
a total of 300 syllables in each sample. Speaking
rate was measured as the number of syllables
per minute (spm).  e frequency of disfl uencies
in each context was measured as the percentage
of total syllables stuttered (%SS), with results as
follows:”
CONTEXT
Speaking Rate
(spm)
Frequency of
Dis uencies (%SS)
Monologue 190 11
Dialogue 196 12.5
Reading 183 9
“Disfl uencies generally occurred in clusters and
consisted primarily of stutter- like disfl uencies (SLDs),
which included sound repetitions (e.g., m- m- my name
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 disfl uencies. When results were
combined across speaking contexts, SLDs represented
83% of total disfl uencies; non- SLDs represented only
17% of total disfl uencies.  e average duration of the
three longest disfl uencies was approximately 2.5seconds.
Frequent accessory behaviors were observed, including
fi nger tapping, head movements, and obvious facial
tension.”
3. For formal measures, provide an introductory
statement that includes the full test name,
abbreviated test name in parentheses, and a
brief description. For example: “ e Stuttering
Instrument–4 (SSI- 4) was completed based on
speech sample results.  is measure provides a
severity rating based on quantifi cation of core
stuttering behaviors and accompanying physical
symptoms.”
4. Provide a summary of derived scores in a table
form followed by a paragraph that interprets
and explains these results. For example: “Overall
scores obtained on the SSI- 4 fell between the
61st and 77th percentile, which means that this
child demonstrated greater disfl uency than 61%
to 77% of children his age.  ese results indicate
a moderate stuttering disorder.”
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ASSESSMENT OF FLUENCY DISORDERS 375
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13
5. To report results of scales measuring percep-
tions, attitudes, or feelings, provide the scale
name, authors, year of publication, and what
the scale purports to measure. In paragraph
form, describe the client’s responses and how
these compare to original fi ndings reported by
the author(s) for stuttering and nonstuttering
individuals. For example: “ e S- 24 (Andrews
& Cutler, 1974) was administered to assess the
client’s general attitude toward communication.
 e client’s total score was 18, which indicates
distinctly negative reactions toward disfl uen-
cies and communication overall.  is score
corresponds to normative data obtained for
stuttering adults (mean " 19.22) rather than
nonstuttering adults (9.14), suggesting that the
client strongly identifi es with perceptions and
attitudes that are typical of people who stutter.”
6. Describe stimulability testing and results. For
example: “Brief trials of pull- outs were at-
tempted with the client following an explana-
tion and demonstration; however, the client
had signifi cant diffi culty identifying discrete
moments of disfl uency.”
Case History (Preschool)
Eric is a 3;2-year-old boy who began showing signs
of childhood stuttering several months ago when
his family moved to a new apartment. Based on his
mother’s description, disfl uencies increased approxi-
mately 1month following onset and now consist of fre-
quent repetitions of phrases, whole words, and sounds.
Eric’s mother has also noticed tension around his face
and mouth when he is struggling to produce certain
words. She is especially concerned because there is a
history of stuttering in Eric’s father’s family.
Selection of Assessment Procedures (Preschool)
Several types of interactions were planned and
recorded in order to obtain representative samples
of Eric’s speech: (1) play interaction with Eric and
his parents at the clinic, (2) play interaction with
Eric and the clinician, and (3) conversational inter-
action with Eric and his parent at home. An infor-
mal analysis of all speech samples was completed in
order to determine the overall frequency of disfl uen-
cies and individual frequencies of SLDs versus ODs.
Two measures were used in order to interpret speech
sample results.  e Stuttering Severity Instrument–4
(SSI- 4) was selected as an age- appropriate standard-
ized measure of stuttering severity and the Pindzola
Protocol for Diff erentiating the Incipient Stutterer
was selected in order to determine whether Eric’s
disfl uencies were developmentally typical or not.
Core subtests of the Clinical Evaluation of Language
Fundamentals–Preschool 2 (CELF- Preschool 2) were
also administered to screen language skills and con-
fi rm that disfl uencies were not related to weaknesses
in language processing.
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376 CHAPTER 13
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 fl uency evaluation due to parental concern regard-
ing stuttering. Eric was accompanied by his mother, Ms. Taylor, who served as a reliable informant.  e
presenting problem, as described by Eric’s mother, was increasing disfl uency 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. Disfl uencies
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. Disfl uencies occur throughout the day and are accompanied by visible tension around the face,
which have become somewhat more pronounced over the past several weeks.  ere 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)
SAMPLE REPORT (PRESCHOOL)
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ASSESSMENT OF FLUENCY DISORDERS 377
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Goldman- Fristoe Test of Articulation
Speech Sample Analysis (plays with clinician, plays with parent, home sample)
Informal Fluency Analysis
Protocol for Diff erentiating 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 aff ect 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 refl exes 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*
Word structure 13*
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 fi ndings. Eric responded appropriately to questions and directions during play and expressed
himself in short but complete sentences with age- appropriate vocabulary and syntax.
SAMPLE REPORT (PRESCHOOL), continued
(Continues)
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378 CHAPTER 13
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
 ree 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 fi ndings across contexts.
Analysis of core stuttering behaviors was based on a total of 800 syllables and revealed the following:
Number of dis uencies per 100 syllables (% stuttered syllables) 19
Number of stutter- like dis uencies (within- word) per 100 syllables 15
Number of developmentally typical dis uencies per 100 syllables 4
Overall frequency of disfl uencies was approximately 19% of total syllables, with the majority of disfl uencies
occurring in clusters (multiple disfl uencies per utterance). Disfl uency types consisted primarily of within-
word disfl uencies (also known as “stutter- like disfl uencies”), which are generally considered atypical.  ese
included blocks, sound prolongations, sound repetitions, syllable repetitions, and monosyllabic word rep-
etitions. Some between- word disfl uencies were observed (e.g., phrase repetitions, interjections, revisions);
however, the majority of disfl uencies in the sample did not fall in this category.
Disfl uency types and frequency of each type (expressed as a percentage of total syllables in the sample,
or %SS) were as follows:
Between- Word Dis uencies
(more typical)
Within- Word Dis uencies
(less typical)
Dis uency Type Frequency (%SS) Dis uency 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
SAMPLE REPORT (PRESCHOOL), continued
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ASSESSMENT OF FLUENCY DISORDERS 379
FLUENCY DISORDERS
13
When disfl uencies involved repetition, the typical number of reiterations was 2- 3; the average duration
of the 3 longest disfl uencies 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 disfl uency. Two standardized stutter-
ing measures were completed based on Eric’s sample and are described below.
 e Protocol for Diff erentiating the Incipient Stutterer (Pindzola & White, 1986) is designed to identify
preschool children whose stuttering is likely to persist based on specifi c disfl uency parameters. Total score is
based on measurement of auditory behaviors (frequency, type, and duration of disfl uencies) as well as visual
evidence of accessory behaviors. Eric’s results were as follows:
Protocol for Diff erentiating the Incipient Stutterer
Total score 35
Interpretation Probably atypical*
*1–20 " probably typical; 20–42 " probably atypical.
 e Stuttering Severity Instrument–4 (SSI- 4) provides a severity rating based on quantifi cation 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 ! 531
Percentile 89th–95th
Severity Severe
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 disfl uency. 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 fl uency 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 disfl uen-
cies that were primarily atypical, and that were frequently accompanied by visible tension around the face
SAMPLE REPORT (PRESCHOOL), continued
(Continues)
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380 CHAPTER 13
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 fi ndings and demonstrated awareness of the following:
1. Indirect strategies for fl uency management were discussed with parent with specifi c recommendations
including: parental use of slower speech rate; regular one- on- one time with Eric during which specifi c
methods for reinforcing fl uency can be implemented; avoiding negative reactions, such as anxiety, fear,
or sadness in response to Eric’s disfl uencies; use of consistent turn- taking during conversations, with
care to avoid “talking over” each other.
2. Direct fl uency treatment: teach Eric to use slow, easy speaking patterns, implement fl uency-
supporting patterns of conversation.
3. Home therapy program to reinforce treatment goals: specifi c exercises to practice treatment targets,
inclusion of siblings.
______________________________ Date_______________
(Name of clinician or clinical supervisor and credentials)
Speech Language Pathologist
SAMPLE REPORT (PRESCHOOL), continued
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ASSESSMENT OF FLUENCY DISORDERS 381
FLUENCY DISORDERS
13
Case History (School- Age)
Emily is a 7- year- old child who briefl y stuttered at
age 2 and is now showing re occurrence of stuttering
symptoms. Based on her mother’s description, disfl uen-
cies fl uctuate in frequency and severity but are consis-
tently observed on most days. Disfl uencies reportedly
consist of word and syllable repetitions with no obvious
signs of tension or struggle. Emily is an outgoing and
popular child and does not seem to avoid speaking situ-
ations; however, her mother was concerned that Emily
may be privately self- conscious or ashamed about her
stuttering and that this might eventually limit her either
academically and/or socially.
Selection of Assessment Procedures
(School- Age)
 ree tasks were selected in order to obtain representa-
tive samples of Emily’s speech: monologue, dialogue, and
reading. For the monologue sample, Emily summarized
the plot of a movie she had recently seen.  e reading
task was based on a simple story book at the fi rst- grade
level. An informal analysis of each speech sample was
completed to determine the overall frequency of dis-
fl uencies and relative frequencies of SLDs versus ODs.
 e Stuttering Severity Instrument–4 (SSI- 4) was
selected as an age- appropriate standardized measure of
stuttering severity.  e A- 19 (Andre & Guitar, 2006)
was administered in order to assess Emily’s underly-
ing attitudes about her speech and about communica-
tion.  e Expressive and Receptive One- Word Picture
Vocabul ar y Te sts were s el ec te d a s ag e- appropriate stan-
dardized measures of vocabulary skills in order to com-
pare receptive and expressive word knowledge and rule
out possible word- retrieval diffi culties.
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382 CHAPTER 13
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 fl uency. 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 disfl uency eventually resolved.
Recent re emergence of stuttering symptoms was noted just after the summer and has been consistently
observed since then, both at home and school. Disfl uency appears to fl uctuate in frequency and severity
without any identifi able triggers. As described by Mrs. Ross, disfl uencies 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 specifi c fears or anxiety related to speaking. Family history is signifi cant for several relatives with
stuttering, some with persisting severe disfl uency 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.  ere 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.
SAMPLE REPORT (SCHOOL- AGE)
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ASSESSMENT OF FLUENCY DISORDERS 383
FLUENCY DISORDERS
13
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
 e Receptive One- Word Picture Vocabulary Test (ROWPVT) and Expressive One- Word Picture
Vocabul ar y Tes t (E OW PV T) were ad mi ni stered to sc reen ba si c vocabu lar y skills an d c ompare re ce pt ive
and expressive word knowledge.  e 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 specifi city and range
of vocabulary appeared generally appropriate for Emily’s age level. During the story retell task, Emily se-
quenced events accurately and provided a coherent story with much description. Eye contact, turn- taking,
and other social conventions during conversation were all appropriate.
Fluency
Core Behaviors
Speech samples were obtained in several contexts, including conversation, monologue, and reading.
 e 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 disfl uency during
speaking tasks was 9.3% of total syllables in conversation and 8.8% of total syllables during extended
speaking (monologue). Disfl uencies consisted of word (“and- and- and”) and part- word (“pe- pe- pe-
people”) repetitions, usually with 2–3 reiterations.  e longest duration of disfl uencies was between 1.0
SAMPLE REPORT (SCHOOL-AGE), continued
(Continues)
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384 CHAPTER 13
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 disfl uency. 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 disfl uencies. 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 dis uency 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.  is 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 disfl uencies 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 disfl uencies in any signifi cant way at this point.
A brief telephone conference with Emily’s classroom teacher, Ms.  omas, on 5/2/10 corroborated the
A- 19 fi ndings described above. Ms.  omas 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 confi dent student who communicates freely despite occasional disfl uency. No teasing or bullying was
reported.
Stimulability
Stimulability was assessed via several trials of fl uency- 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.
SAMPLE REPORT (SCHOOL-AGE), continued
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ASSESSMENT OF FLUENCY DISORDERS 385
FLUENCY DISORDERS
13
Emily responded well to all methods following brief explanation and demonstration. Several trials of pull-
outs were attempted; however, these seemed more diffi cult for Emily because her disfl uencies tended to
have a short duration and her speech rate was often too rapid for her to identify and modify moments of
disfl uency eff ectively.
V. Summary and Recommendations
Emily is a 7-year-old daughter with a borderline mild- moderate fl uency disorder. Her disfl uencies 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 fi nd this helpful, and has no other eff ective means
of managing disfl uencies. Indirect and direct speech therapy is recommended, focusing on implementing
methods to promote fl uency at home and school, educating Emily and her family about stuttering, prac-
ticing strategies for fl uent speech, and managing moments of disfl uency as they occur. It is important for
Emily to have an eff ective 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 fl uency
is being properly supported at home and in school. Finally, Emily may benefi t 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 benefi t from the experiences
of other children with similar diffi culties.
________________________________Date_______________
(Name of clinician or clinical supervisor and credentials)
Speech- Language Pathologist
SAMPLE REPORT (SCHOOL-AGE), continued
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386 CHAPTER 13
Case History (Adult)
Amanda is a 22- year- old college student referred for a
fl uency evaluation by her college counselor. She is cur-
rently majoring in theatre and aspires to become a the-
atre director. Amanda began stuttering when she was 5
and has stuttered fairly consistently since then. She was
evaluated previously but has never received interven-
tion. Her stuttering is characterized by several types of
disfl uencies (repetitions, prolongations, interjections), in
addition to certain accessory behaviors and avoidances.
Amanda is comfortable speaking with most people and
is not ashamed of her stuttering, but is anxious about
how stuttering may aff ect her future career.
Selection of Assessment Procedures (Adult)
Representative samples of Amanda’s speech were
obtained in three contexts: monologue, dialogue, and
reading. A timed monologue was also recorded to
measure the eff ect of imposed pressure on disfl uencies.
Informal fl uency analyses were performed on the three
samples to determine speaking rate, disfl uencies per
minute, disfl uency types, and disfl uency durations.  e
Locus of Control of Behavior Scale was selected as an
age- appropriate informal measure of attitudes and con-
fi dence level related to daily communication situations.
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ASSESSMENT OF FLUENCY DISORDERS 387
FLUENCY DISORDERS
13
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 fl uency. 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,
illnesses, or hospitalizations were reported.
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 f riends, watching television,
writing, and reading novels.
Educational/Occupational History
Amanda attended high school in the United States and is currently in her fi fth 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.
SAMPLE REPORT (ADULT)
(Continues)
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388 CHAPTER 13
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 specifi c 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 fl uently.
She is anxious when producing new and long words and experiences the most diffi culty at school, where
she feels that her stuttering may be hindering her class work. She is also concerned that her disfl uency may
interfere with her ability to communicate eff ectively 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 fi rst 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.  erapy was recommended; however, Amanda
did not pursue services at that time. Information obtained from the present evaluation corroborated previ-
ous assessment fi ndings.
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.
SAMPLE REPORT (ADULT), continued
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ASSESSMENT OF FLUENCY DISORDERS 389
FLUENCY DISORDERS
13
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 eff ectively.
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 disfl uencies, duration of disfl uency, 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.  e 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.  ese results indicated that
Amanda had a reduced speech rate for oral reading. She exhibited a total number of 21 disfl uencies 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 disfl uencies was between 0.5 and 1.0seconds during oral reading.
Amanda exhibited some secondary characteristics, including head jerking on fi rst 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
in reading, Amanda spoke at an appropriate speech rate during monologue. She exhibited a total of
20 disfl uencies, primarily initial sound repetitions and interjections. Duration of disfl uencies was 0.5sec-
onds for monologue. A timed monologue was elicited to determine the eff ects of imposed time pressure on
Amanda’s fl uency. Results of a 1- minute sample revealed no change in her fl uency patterns.
Conversation
In conversation, Amanda spoke at an average rate of approximately 93wpm.  e average rate for conver-
sational speech in adults is 115–165wpm (Andrews & Ingham, 1971).  erefore, 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 disfl uencies, including a combination of sound, whole- word and phrase repetitions,
interjections (e.g., “umm”), and prolongations (e.g., “aaaand”).  e duration of Amanda’s disfl uencies was
between 0.5 and 1.0seconds for conversation. During this task, Amanda exhibited some secondary char-
acteristics, such as averting eye contact.
SAMPLE REPORT (ADULT), continued
(Continues)
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390 CHAPTER 13
SPEECH-LANGUAGE EVALUATION
In summary, the duration of Amanda’s disfl uencies 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.  is is due to the types of disfl uencies 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
CONTEXT
Rate of
Speech (wpm)
Dis uencies
per minute Duration Types of Dis uencies
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
 e attitudes and emotions component of the evaluation assessed how Amanda feels about her stuttering
in terms of self- esteem, locus of control, and assertiveness.  e Locus of Control of Behavior Scale was
administered and it assessed Amanda’s self- confi dence and attitudes in daily communication situations.
 e 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 confi rmed 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 diffi culties and take action to avoid them.”
Stimulability Testing
A trial of stuttering intervention was presented during the session.  e tasks involved using various fl uency-
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 disfl uencies 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 disfl uency. As evidenced by the Locus of Control of Behavior Scale, Amanda did not
present with any confi rmed attitudinal perceptions regarding her stuttering. Prognosis for improvement
SAMPLE REPORT (ADULT), continued
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ASSESSMENT OF FLUENCY DISORDERS 391
FLUENCY DISORDERS
13
is good, due to the client’s motivation, awareness of disfl uencies, positive perception of speaking abilities,
and stimulability for using fl uency- 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 fl uency issues and goals related to future activities/plans: Amanda’s intervention
should emphasize stuttering education, self- awareness of disfl uent 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 fl uent 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.
________________________________Date_______________
(Name of clinician or clinical supervisor and credentials)
Speech- Language Pathologist
SAMPLE REPORT (ADULT), continued
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392 CHAPTER 13
NOVEL CASE HISTORIES
FOR PRACTICE
Next we present concluding paragraphs from two
diagnostic reports.  e fi rst evaluation was conducted
with Michael, a 2- year, 5- month- old child who began
showing questionable signs of childhood stuttering
13months prior to assessment.  e second evaluation
was conducted with Julie, a 31- year- old female with a
long history of stuttering. After reading each paragraph,
select specifi c formal and informal procedures that could
have led to the conclusions described. Explain how each
procedure would have been implemented, how it would
contribute to the diagnostic conclusion, and how spe-
cifi c fi ndings from that procedure or analysis would be
reported in the full text of the evaluation.
Case 1: Michael Davis, a 2- year, 5- month- old
child, was seen for a speech and language evaluation to
assess parental concerns regarding stuttering. Findings
revealed mild stuttering characterized by a relatively
low frequency of disfl uencies, brief duration of disfl u-
encies, and no evidence of tension or struggle. Overall,
results were more consistent with developmentally
typical disfl uency rather than beginning stuttering.
Language skills, articulation, and vocal function were
all age appropriate.
Case 2: Julie Russo, a 31- year- old female, was seen
for a fl uency evaluation to assess concerns relating to
a long history of stuttering. Findings revealed a severe
stuttering disorder marked by frequent, long blocks that
occurred across speaking contexts and that were usually
accompanied by signifi cant facial tension, head move-
ment, and/or audible gasping. Assessment of Julie’s
feelings related to her speech indicated signifi cant
negative reactions to her stuttering, strong identifi ca-
tion with perceptions and attitudes that are typical of
people who stutter, and a number of specifi c fears and
avoidance behaviors.
GLOSSARY
Accessory behaviors: behaviors that begin as an at-
tempt to push out of disfl uencies but eventually be-
come learned patterns that accompany core stuttering
behaviors.
Avoidance behaviors: attempts to circumvent mo-
ments of disfl uency.
Between- word dis uencies: discontinuities interfering
with smooth transitioning between words in an utter-
ance (phrase repetitions, interjections, running starts,
revisions).
Blocks: a form of disfl uency in which both airfl ow and
sound are stopped during the production of speech.
Broken words: a form of disfl uency involving a tense,
silent pause in the middle of a vowel, followed by abrupt
reinitiation of voicing.
Clusters: the occurrence of two or more disfl uencies on
the same word or utterance.
Cluttering: a fl uency disorder characterized by pri-
marily typical forms of disfl uency, as well as possible
abnormalities in speech rate, language formulation, ar-
ticulation, and self- monitoring.
Core behaviors: involuntary discontinuities in the fl ow
of speech that represent the key features of stuttering
(e.g., repetitions, prolongations, blocks).
Dis uency: speech that is not fl uent (does not neces-
sarily imply abnormality).
Dys uency: a lack of fl uency that is deemed abnormal.
Escape behaviors: speaker’s attempt to terminate a
block (e.g., by blinking, stamping feet, moving head).
Incipient stuttering: early signs of a stuttering disorder
(vs. developmental disfl uencies).
Interjections: insertion of extraneous, meaningless
words or phrases into the fl ow of connected speech
(e.g., “um,” “you know”); often called fi llers.
Locus of control of behavior (LCB): the extent to which
the outcome of events is attributed to external circum-
stances versus internal factors.
Prolongations: a form of disfl uency in which sound or
airfl ow continues, but articulatory movement is stopped.
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ASSESSMENT OF FLUENCY DISORDERS 393
FLUENCY DISORDERS
13
Real- time analysis: disfl uency analysis performed
while the speech sample is being obtained.
Repetition: a typical or atypical form of disfl uency that
involves reiterations of a phrase, word, syllable, or sound.
Revisions: a form of disfl uency (or escape behavior) in
which phrases or sentences are reformulated, often to
avoid anticipated diffi culty on a particular word or sound.
Running starts: a form of disfl uency (or escape behav-
ior) in which the speaker returns once or several times
to the beginning of a thought or sentence in order to
regain fl uency.
Spontaneous recovery: recovery from childhood stut-
tering without any formal intervention or treatment.
Stutter- like dis uencies (SLDs): disfl uencies associated
with more chronic forms of stuttering, sometimes re-
ferred to as within- word disfl uencies.
Tremors: small, rapid muscle contractions.
Within- word dis uencies: discontinuities that interfere
with smooth transitioning between sounds or syllables
within a word (sound repetitions, syllable repetitions,
prolongations, blocks, broken words).
REFERENCES
Adams,M.R. (1999). A perspective on stuttering.
Contemporary Issues in Communication Science and
Disorders, 26, 5–13.
Ambrose,N.G., & Yairi,E. (1999). Normative dis-
fl uency data for early childhood stuttering. Journal of
Speech, Language, and Hearing Research, 42, 895–909.
American Speech- Language- Hearing Association.
(1999). Terminology pertaining to fl uency and fl uency
disorders: Guidelines. Retrieved from http://www
.asha.org/policy.
Anderson,J.D., & Conture,E.G. (2000). Language
abilities of children who stutter: A preliminary study.
Journal of Fluency Disorders, 25, 283–304.
Andre,S., & Guitar,B. (2006). A- 19 Scale for Children
Who Stutter. In B.Guitar (Ed.), Stuttering: An Integrated
Approach to Its Nature and Treatment (pp. 196–197).
Baltimore, MD: Lippincott Williams & Wilkins.
Andrews,G. & Ingham,R.J. (1971). Stuttering:
Considerations in the evaluation of treatment. British
Journal of Disorders of Communication. Oct. 6(2):
129–138.
Andrews,G., Craig,A., Feyer,A.M., Hoddinott,S.,
Howie,P., & Neilson,M. (1983). Stuttering: A review
of research fi ndings and theories circa 1982. Journal of
Speech and Hearing Disorders, 48, 226–246.
Andrews,G., & Cutler,J. (1974).  e relation between
changes in symptom level and attitudes. Journal of
Speech and Hearing Disorders, 39, 312–319.
Baron- Cohen,S. (2008). Autism, hypersensitization,
and truth.  e Quarterly Journal of Experimental
Psychology, 61(1), 64–75.
Beitchman,J.H., Nair,R., Clegg,M., & Patel,P.G.
(1986). Prevalence of speech and language disorders
in 5- year-old kindergarten children in the Ottawa-
Carleton region. Journal of Speech and Hearing
Disorders, 51, 98–110.
Block,S., Onslow,M., Packman,A., & Dacakis,G.
(2006). Connecting stuttering management and
measurement: IV. Predictors of outcome for a behav-
ioural treatment for stuttering. International Journal of
Language and Communication Disorders, 41, 395–506.
Bloodstein,O. (1995). A Handbook on Stuttering. San
Diego, CA: Singular Publishing Group.
Bloodstein,O. (2006). Some empirical observations
about early stuttering: A possible link to language
development. Journal of Communication Disorders, 39,
185–191.
Bloodstein,O., & Bernstein Ratner,N. (2008).
A Handbook on Stuttering (6th ed.). Clifton Park, NY:
Delmar/Cengage Learning.
85327_ch13_ptg01_hr_347-398.indd 393 26/05/11 6:04 PM

394 CHAPTER 13
Boscolo,B., Bernstein Ratner,N., & Rescorla,L.
(2002). Fluency of school- aged children with a his-
tory of specifi c expressive language impairment: An
exploratory study. American Journal of Speech- Language
Pathology, 11, 41–49.
Brosch,S., Haege,A., Kalehne,P., & Johannsen,H.S.
(1999). Stuttering children and the probability of
remission—the role of cerebral dominance and
speech production. International Journal of Pediatric
Otohinolaryngology, 47, 71–76.
Brutten,G., & Dunham,S. (1989).  e Communica-
tion Attitude Test: A normative study of grade
school children. Journal of Fluency Disorders, 14,
371–377.
Brutten,G., & Vanryckeghem,M. (2003). En
evidence- based en multi- dimensional onderzoeksinstru-
ment voor kinderen die stotteren bruikbaar voor diff eren-
tiaaldiagnostische en therapeutische besluitvorming
[An evidence- based and multi- dimensional assessment
instrument for children who stutter for the purpose of
diff erential diagnostic and therapeutic decision making].
Stichting Integratie Gehandicapten, Belgium & Acco
Publishers, the Netherlands.
CareyW.B., & McDevitt,S.C. (1995). Coping with
children’s temperament: A guide for professionals. New
York: BasicBooks.
Cooper,E.B. (1973).  e development of a stuttering
chronicity prediction checklist: A preliminary report.
Journal of Speech and Hearing Disorders, 38, 215–223.
Cooper,E.B., & CooperC.S. (1985). Personalized
Fluency Control  erapy. Allen,TX: DLM.
Cordes,A.K. (2000). Individual and consensus judg-
ments of disfl uency types in the speech of persons
who stutter. Journal of Speech, Language, and Hearing
Research, 43, 951–964.
Craig,A., & Andrews,G. (1985).  e prediction
and prevention of relapse in stuttering:  e value of
self- control techniques and locus of control measures.
Behavior Modifi cation, 9, 427–442.
Craig,A., Franklin,J.A., & Andrews,G. (1984).
A scale to measure locus of control of behaviour.
British Journal of Medical Psychology, 57, 173–180.
Crowe,T.A., Di Lollo,A., & Crowe,B.T. (2000).
Crowe’s Protocols: A Comprehensive Guide to Stutter-
ing Assessment. San Antonio, TX:  e Psychological
Corporation.
Curlee,R.F. (1999). Identifi cation and case selec-
tion guidelines for early childhood stuttering. In
R.F.Curlee (Ed.), Stuttering and Related Disorders
of Fluency (2nd ed., pp. 1–21). New York:  ieme
Medical Publishers.
Daly,D.A., & Burnett,M.L. (1999). Cluttering:
Tr ad it i on a l vi e ws a n d ne w pe r sp e ct iv e s. In R. F.C ur l ee
(Ed.), Stuttering and Related Disorders of Fluency (2nd ed.,
pp. 222–254). New York:  ieme Medical Publishers.
Daly,D.A., & Cantrell,R.P. (2006). Cluttering char-
acteristics identifi ed as diagnostically signifi cant by
60 fl uency experts. In Proceedings of the Second World
Congress on Fluency Disorders.
De Nil,L.F., & Brutten,G.J. (1991). Speech-
associated attitudes of stuttering and nonstuttering
children. Journal of Speech and Hearing Research, 34,
60–66.
De Nil,L.F., & Kroll,R.M. (1995). 
e relation-
ship between locus of control and long- term stutter-
ing treatment outcome in adult stutterers. Journal of
Fluency Disorder, 20, 345–364.
Duchin,S., & Mysak,E. (1987). Disfl uency and rate
characteristics of young adult, middle- aged, and
elderly males. Journal of Communication Disorders, 20,
245–257.
Gordon,P.A., & Luper,H.L. (1992a).  e early
identifi cation of beginning stuttering I: Protocols.
American Journal of Speech Language Pathology, 1,
43–53.
Gordon,P.A., & Luper,H.L. (1992b).  e early
identifi cation of beginning stuttering II: Problems.
American Journal of Speech Language Pathology, 1,
49–55.
85327_ch13_ptg01_hr_347-398.indd 394 26/05/11 6:04 PM

ASSESSMENT OF FLUENCY DISORDERS 395
FLUENCY DISORDERS
13
Gregory,H.H., & Hill,D. (1999). Diff erential
evaluation— diff erential therapy for stuttering children.
In R.F.Curlee (Ed.), Stuttering and Related Disorders
of Fluency (2nd ed., pp. 22–42). New York:  ieme
Medical Publishers.
Guitar,B. (2006). Stuttering: An Integrated Approach
to Its Nature and Treatment (3rd ed.). Baltimore, MD:
Lippincott, Williams, & Wilkins.
Halpern,D.F., (1997). Sex diff erences in intelligence:
Implications for education. American Psychologist, 52,
1091–1102.
Healey,C.E., Scott-Trautman,L., & Susca,M.
(2004). Clinical applications of a multidimensional
approach for the assessment and treatment of stutter-
ing. Contemporary Issues in Communication Science and
Disorders, 31, 40–48.
Hubbard,C.P., & YairiE. (1988). Clustering of dis-
fl uencies in the speech of stuttering and nonstutter-
ing preschool children. Journal of Speech and Hearing
Research, 31, 228–233.
Jezer,M. (1997). Stuttering: A Life Bound Up in Words.
New York: Harper Collins Publishers.
Kloth,S.A.M., Kraaimaat,F.W., Janssen,P., &
Brutten,G.J. (1999). Persistence and remission of in-
cipient stuttering among high- risk children. Journal of
Fluency Disorders, 24, 253–265.
Ladouceur,R., Caron,C., & Caron,G. (1989).
Stuttering severity and treatment outcome. Journal
of Behavior  erapy and Experimental Psychiatry, 20,
49–56.
Lanyon,R.I. (1967).  e measurement of stuttering
severity. Journal of Speech and Hearing Research, 10,
836–843.
LaSalle,L.R., & Conture,E.G. (1995). Disfl uency
clusters of children who stutter: Relation of stutterings
to self- repairs. Journal of Speech and Hearing Research,
38, 965–977.
Leith,W.R., Mahr,G.C., & Miller,L.D. (1993).
 e assessment of speech- related attitudes and beliefs
of people who stutter. ASHA Monographs, 29, 1–32.
Logan,K.J., & LaSalle,L.R. (1999). Grammatical
characteristics of children’s conversational utterances
that contain disfl uency clusters. Journal of Speech,
Language, and Hearing Research, 42, 80–91.
McDevitt,S.C., & Carey,W.B. (1978).  e measure-
ment of temperament in 3–7-year-old children. Journal
of Child Psychology and Psychiatry, 19, 245–23.
McDonough,A.N., & Quesal,R.W. (1988). Locus
of control orientation of stutterers and nonstutterers.
Journal of Fluency Disorders, 13, 97–106.
Meyers,S.C. (1986). Qualitative and quantitative
diff erences and variability in disfl uencies emitted by
preschool stutterers and nonstutterers during dyadic
conversations. Journal of Fluency Disorders, 11,
293–306.
Pellowski,M.W., & Conture,E.G. (2002).
Characteristics of speech disfl uency and stuttering be-
haviors in 3- and 4-
year old children. Journal of Speech,
Language, and Hearing Research, 45, 20–34.
Perkins,W.H., Kent,R.D., & Cur lee,R.F. (1991).
A theory of neuropsycholinguistic function in stutter-
ing. Journal of Speech and Hearing Research,34, 734–752.
Pindzola,R.H., Jenkins,M.M., & Lokken,K.J.
(1989). Speaking rates of young children. Language,
Speech, and Hearing Services in Schools, 20, 133–138.
Pindzola,R.H., & White,D.T. (1986). A protocol
for diff erentiating the incipient stutterer. Language,
Speech, and Hearing in Schools, 17, 2–15.
Quesal,R.W. (1988). Inexact use of “disfl uency” and
“dysfl uency” in stuttering research. Journal of Speech and
Hearing Disorders, 53, 349, 350.
Ramig,P.R. (1993). High reported spontaneous stut-
tering recovery rates: Fact or fi ction? Language, Speech,
and Hearing Services in Schools, 24, 156–160.
Rathus,S.A. (1973). A 30- item schedule for assessing
assertive behavior. Behavior  erapy, 4, 398–406.
Reilly,S., Onslow,M., Packman,A., Wake,W.,
Bavin,E.L., Prior,M., Eadie,P., Cini,E.,
Bolzonello,C., & Ukuomunne,O.C. (2010).
Predicting stuttering onset by the age of 3years:
85327_ch13_ptg01_hr_347-398.indd 395 26/05/11 6:04 PM

396 CHAPTER 13
A prospective, community cohort study. Pediatrics, 123,
270–277.
Riley,G. (1981). Stuttering Prediction Instrument for
Young Children (3rd ed.). Austin, TX: Pro- Ed.
Riley,G. (2009). SSI- 4: Stuttering Severity
Instrument— Fourth Edition. Austin, TX: Pro- Ed.
Riley,J., Riley,G., & Maguire,G. (2004). Subjective
screening of stuttering severity, locus of control
and avoidance: Research edition. Journal of Fluency
Disorders, 29, 51–62.
Robb,M.P., Sargent,A., & O’Beirne,G.A. (2009).
Characteristics of disfl uency clusters in adults who
stutter. Logopedics Phoniatrics Vocology, 34, 36–42.
Rommel,D., Hage,A., Kalehne,P., & Johannsen,H.S.
(2000). Development, mainte ance, and recovery of
childhood stuttering: Prospective longitudinal data
3years after fi rst contact. In K.L.Baker, L.Rustin,
& F.Cook (Eds.), Proceedings of the Fifth Oxford
Disfl uency Conference (pp. 168–182).
Rosenberg,M. (1979). Conceiving the Self. New York:
Basic Books.
Rotter,J.B. (1966). Generalized expectancies for
internal versus external control or reinforcement.
Psychological Monographs: General and Applied, 80, 1–28.
Rousseau,I., Onslow,M., Packman,A., & Jones,M.
(2008). Comparisons of audio and audiovisual mea-
sures of stuttering frequency and severity in preschool-
age children. American Journal of Speech- Language
Pathology, 17, 173–178.
Sawyer,J., & Yairi,E. (2006).  e eff ect of sample
size on the assessment of stuttering severity. American
Journal of Speech- Language Pathology, 15, 36–44.
Schwartz,M.F. (1974).  e core of the stuttering
block. Journal of Speech and Hearing Disorders, 39,
169–177.
Shapiro,D.A. (1999). Stuttering intervention: A collab-
orative journey to fl uency freedom. Austin, TX: Pro- Ed.
Shaywitz,B.A., Shaywitz,S.E., Pugh,K.R.,
Constable,R.T., Skudlarski,P., Fulbright,R.K.,
Bronen,R.A., Fletcher,J.M., Shankweiler,D.P.,
Katz,L., & Gore,J.C. (1995). Sex diff erences in the
functional organization of the brain for language.
Nature, 373, 607–609.
Sheehan,J.G. (1970). Stuttering: Research and therapy.
New York: Harper and Row Publishers.
Shenker,R.C. (2006). Connecting stuttering manage-
ment and measurement: I. Core speech measures of
clinical process and outcome. International Journal of
Language and Communication Disorders, 41, 355–364.
Shipley,K., & McAfee,J. (2008). Assessment in
Speech- Language Pathology: A Resource Manual, 4th
edition, Delmar/Cengage Learning.
Silverman,F.H. (1980).  e Stuttering Problem
Profi le: A task that assists both client and clinician in
defi ning therapy goals. Journal of Speech and Hearing
Disorders, 45, 119–123.
Smith,A. (1990). Toward a comprehensive theory
of stuttering: A commentary. Journal of Speech and
Hearing Disorders, 55, 398–401.
Smith,A., McCauley,R.J., & Guitar,B. (2000).
Development of the Teacher Assessment of Student
Communicative Competence (TASCC) in Grades 1
through 5. Communication Disorders Quarterly, 22,
3–11.
Sommer,M., Koch,M.A., Paulus,W., Weiller,C., &
Buchel,C. (2002). Disconnection of speech- relevant
brain areas in persistent developmental stuttering.
Lancet, 360, 380–383.
St. Clare,T., Menzies,R.G., Onslow,M.,
Packman,A.,  ompson,R., & Block,S. (2009).
Unhelpful thoughts and beliefs linked to social anxiety
in stuttering: Development of a measure. International
Journal of Language and Communication Disorders, 44,
338–351.
St. Louis,K.O., & Myers,F.L. (1997). Management
of cluttering and related fl uency disorders. In
R.F.Curlee & G.M.Siegel (Eds.), Nature and
treatment of stuttering: New directions (pp. 313–332).
Needham Heights, MA: Allyn & Bacon.
St. Louis,K.O., Myers,F.L., Bakker,K., &
Raphael,L.J. (2007). Understanding and treating of
85327_ch13_ptg01_hr_347-398.indd 396 26/05/11 6:04 PM

ASSESSMENT OF FLUENCY DISORDERS 397
FLUENCY DISORDERS
13
cluttering. In E.G.Conture & R.F.Curlee (Eds.),
Stuttering and Related Disorders of Fluency (pp. 297–325).
New York:  ieme Medical Publishers.
Starkweather,C.W., & Givens- Ackerman. (1997).
Stuttering. Austin, TX: Pro- Ed.
Starkweather,C.W., & Gottwald,S.R. (1990).  e
demands and capacities model II: Clinical applications.
Journal of Fluency Disorders, 15, 143–157.
Sturm,J. & Seery,C. (2007). Speech and articulatory
rates of school- age children in conversation and narra-
tive contexts. Language, Speech, and Hearing Services in
Schools, 38, 47–59.
Van R ip er, C . ( 1982 ).  e Nature of Stuttering (2nd ed.).
Englewood Cliff s, NJ: Prentice- Hall.
Van Zaalen,Y., Wijnen,F., & De Jonckere,P.H.
(2009). Diff erential diagnostic characteristics between
cluttering and stuttering— Part one. Journal of Fluency
Disorders, 34, 137–154.
Vanryckeghem,M., & Brutten,G.J. (2007a). Behavior
Assessment Battery for School- Age Children Who Stutter.
San Diego, CA: Plural Publishing.
Vanryckeghem,M., & Brutten,G.J. (2007b).
KiddyCAT: Communication Attitude Test for Preschool
and Kindergarten Children Who Stutter. San Diego, CA:
Plural Publishing.
Wingate,M.E. (1964). A standard defi nition of stut-
tering. Journal of Speech and Hearing Disorders, 29,
484–489.
Wingate,M.E. (2001). SLD is not stuttering. Journal
of Speech, Language, and Hearing Research, 44, 381–383.
Woolf,G. (1967).  e assessment of stuttering as
struggle, avoidance, and expectancy. British Journal of
Disorders of Communication, 2, 158–171.
World Health Organization. (2001).  e International
Classifi cation of Functioning, Disability, and Health.
Geneva: Author.
Wright,L., & Ayre,A. (2000). Wright and Ayre
Stuttering Self- Rating Profi le. Bicester: Speechmark.
Yairi,E. (1997). Disfl uency characteristics of child-
hood stuttering. In R.F.Curlee & G.M.Siegel
(Eds.), Nature and Treatment of Stuttering: New Direc-
tions (pp. 49–78). Needham Heights, MA: Allyn &
Bacon.
Yairi,E., Ambrose,N.G., Paden,E.P., &
 roneburg,R.N. (1996). Predictive factors of persis-
tence and recovery: Pathways of childhood stuttering.
Journal of Communication Disorders, 29, 51–77.
Yairi,E. & Ambrose,N.G. (1999). Early Childhood
Stuttering I: Persistency and Recovery Rates. Journal
of Speech, Language, and Hearing Research, Vol. 42,
1097–1112.
Yairi,E., & Lewis,B. (1984). Disfl uencies at the onset
of stuttering. Journal of Speech and Hearing Research, 27,
154–159.
Yaruss,J.S. (1997). Clinical implications of situational
variability in preschool children who stutter. Journal of
Fluency Disorders, 22, 187–203.
Yaruss,J.S. (1998). Real- time analysis of speech fl u-
ency: Procedures and reliability training. American
Journal of Speech Language Pathology, 7, 25–37.
Yaruss,J.S., Coleman,C., & Quesal,R.W. (2010).
OASES- S: Overall Assessment of the Speaker’s Experience
of Stuttering–School- Age (Ages 7–12). Bloomington,
MN: Pearson Assessments.
Yaruss,J . S., & QuesalR. W. (2006). Overall
Assessment of the Speaker’s Experience of
Stuttering (OASES): Documenting multiple out-
comes in stuttering treatment. Journal of Fluency
Disorders, 31, 90–115.
Yaruss,J.S., & Quesal,R.W. (2010). OASES- A:
Overall Assessment of the Speaker’s Experience of
Stuttering–Adult (Ages 18!). Bloomington, MN:
Pearson Assessments.
Yaruss,J.S., Quesal,R.W., & Coleman,C. (2010).
OASES- T: Overall Assessment of the Speaker’s Experience
of Stuttering–Teenagers (Ages 13–17). Bloomington,
MN: Pearson Assessments.
Zebrowski,P.M., & Conture,E.G. (1989).
Judgments of disfl uency by mothers of stuttering and
normally fl uent children. Journal of Speech and Hearing
Research, 32, 625–634.
85327_ch13_ptg01_hr_347-398.indd 397 26/05/11 6:04 PM

398 CHAPTER 13
Zebrowski,P.M., & Kelly,E.M. (2002). Manual
of stuttering intervention— Clinical competence series.
Clifton Park, NY: Delmar/Cengage Learning.
RECOMMENDED WEBSITES
American Institute for Stuttering
http://www.stutteringtreatment.org
FRIENDS
http://www.friendswhostutter.org
International Stuttering Association
http://www.stutterisa.org
Judith Kuster Homepage about Stuttering
http://www.stutteringhomepage.com
National Stuttering Association
http://www.nsastutter.org
Stuttering Foundation
http://www.stutteringhelp.org
 e Canadian Stuttering Association
http://www.stutter.ca
Selected Journals Related to Stuttering
American Journal of Speech- Language Pathology:
A Journal of Clinical Practice
Contemporary Issues in Communication Science
and Disorders
Journal of Communication Disorders
Journal of Fluency Disorders
Journal of Speech, Language, and Hearing Research
Language, Speech, and Hearing Services in Schools
Perspectives on Fluency and Fluency Disorders (ASHA,
Special Interest Division)
Seminars in Speech and Language
 e Journal of Stuttering  erapy, Advocacy, and Research
Recommended Books about Stuttering
Bennett,E. (2006). Working with People Who Stutter.
A Lifespan Approach. New Jersey: Pearson.
Bloodstein,O., & Bernstein Ratner,N. (2008).
A Handbook on Stuttering (6th ed.). Clifton Park, NY:
Delmar/Cengage Learning.
Bloom,C.M., & Cooperman,D.K. (1999).
Synergistic Stuttering  erapy. A Holistic Approach.
Woburn: MA: Butterworth Heinemann.
Conture,E.G. (2001). Stuttering: Its Nature, Assessment,
and Treatment. Needham Heights, MA: Allyn & Bacon.
Curlee,R.F. (1999). Stuttering and Related Disorders
of Fluency (2nd ed.). New York:  ieme Medical
Publishers.
Curlee,R.F., & Siegel,G. (1997). Nature and Treat-
ment of Stuttering: New Directions (2nd ed.). Needham
Heights, MA: Allyn & Bacon.
Guitar,B. (2006). Stuttering: An Integrated Approach
to Its Nature and Treatment (3rd ed.) Baltimore, MA:
Lippincott, Williams, & Wilkins.
Guitar,B., & McCauley,R. (2009). Treatment of
Stuttering: Established and Emerging Interventions.
Lippincott, Williams & Wilkins.
Manning,W.H. (2009). Clinical Decision Making
in Fluency Disorders (3rd ed.). Clifton Park, NY:
Delmar/Cengage Learning.
Parr y,W. (2006).  e Second Edition— Understanding
and Controlling Stuttering. A Comprehensive New Ap-
proach Based on the Valsalva Hypothesis. Ne w York: NSA.
Ramig,P., & Dodge,D. (2005). Child and Adolescent
Stuttering Treatment and Activity Resource Guide. New
York: Delmar/Cengage Learning.
Reardon,N.A., & Yaruss,J.S. (2004).  e source for
stuttering Ages 7–18. East Moline, IL: LinguiSystems.
Shapiro,D.A. (1999). Stuttering Intervention: A Collab-
orative Journey to Fluency Freedom. Austin, TX: Pro- Ed.
Walton,P., & Wallace,M. (1998). Fun with Fluency.
Direct  erapy with  e Young Child. Imaginart
International, Inc.
Zebrowski,P.M., & Kelly,E.M. (2002). Manual of
Stuttering Intervention—Clinical Competence Series.
Clifton Park, NY: Delmar/Cengage Learning.
85327_ch13_ptg01_hr_347-398.indd 398 26/05/11 6:04 PM