Marisha

Speaker 1: Hello there and welcome to the SLP Now podcast where we share practical therapy tips and ideas for busy speech language pathologists. Grab your favorite beverage and sit back as we dive into this week's episode. Welcome to the SLP Now podcast. This week we are continuing the conversation with Steven, and last week we talked about assessing speech fluency and now we're going to chat about assessing the impact of stuttering. And I know Steven's super excited about this topic and I am too.

Steven: Love it.

Speaker 1: Steven, can you give us a walkthrough of how you would navigate this?

Steven: Yes. So when you're assessing stuttering, you should assess fluency in some way. You should assess their feelings toward their speech in some way. It really helps to augment it with some kind information from familiar listeners like mom or dad or teachers, and then use those three things, fluency feelings and familiar people ratings to land at the functional impact overall of stuttering on their life. So we've done fluency and now we'll talk about how to assess feelings and how to gather in information from familiar listeners. So thankfully there are a lot more things coming online to help us assess the gray kind of vague and fuzzy things about stuttering that isn't just simple speech fluency. And there are some really good standardized assessments. Standardized assessments are great. Of course we know that they've been standardized. The cons of them are that they tend to be expensive, which I know just doesn't work for some of us and they tend to be a little more time consuming.

So you sort of have to balance all the good that can come from a standardized assessment of stuttering impact or feelings about speech with those cons. So I'll walk you through some of kind of the top tier standardized assessments out there and then what I do. So probably the one that people will be most familiar with is the OASES, the overall assessment of the speakers experience of stuttering. This was made by J. Scott Yaruss and his team, it's definitely the one that is used the most in research and it does some really cool things. It gives you based off of client answers to quite a lot of questions on a Likert scale, it gives you a score for general kind of perceptions that the client has about stuttering, a score about the client's reactions to stuttering, a score for difficulties with co communication in daily life situations and then from those three scores it gives you an overall impact score on their quality of life. And that is a great score to have.

The cons are this test takes so long for me to administer. For school-aged kids, they have to answer I think it's 60 questions on a Likert scale, which takes me about 30 minutes if not more, like 35 or 40. For teens, that goes up to 80 items on a Likert scale and for adults it goes up to 100 questions on a five point Likert scale. It gives you really good scores, but I have spent an hour with kids doing it and I just don't always have that time. So then I'm bummed because I don't get those really great scores. But if you can't pay for the test itself or for the forms as you run out or you don't have the time for it, there is another one that I like as well. It's not quite as expansive and comprehensive in scope, but it's still pretty good and it's called the CAT, the Communication Attitude Test.

They have one called the Kitty CAT, which is for three to six years old. The CAT is for six to 14 or 15 year olds and then I think it's called the CAT A or something for adults. And while you can't purchase it on its own, it is subsumed in the BAB, the behavior assessment battery, which I think is kind of funny that you can't just get it on its own. But the good thing is that the BAB is only about 30 bucks. So if you can get that, then you'll get the CAT which is inside of it. Now the CAT, I think for the Kitty CAT, it's 10 or 12 questions, for the CAT for school age kids, I think it's 30 or 32 questions, for adults I forget how many questions it is, but all it is they answer a yes or no question, either yes or no, and then you add up all the yeses and the no's and that gives you a score.

So for instance, answer this with true or false. Sometimes my words stick in my mouth when I talk, true or false. If they say true, that's a point for stuttering. My classmates think that I talk funny, is that true or false? So that'll kind of tell you if they say true, then it means that they know that they get some kind of reactions to the way that they talk. People sometimes finish my words for me, true or false. So while it's either 10 or 12 questions or 30 questions, it's pretty quick, it's just true or false. And from that you get a standardized score based off of samples of peers their same age of, "If you don't stutter, this is your average score with standard deviations. If you do stutter and you're this age, this would be your average score and standard deviations." And you can see where your client falls on those scales. I would say that's the most cost effective and time efficient yet still to get a standardized measure of impact of stuttering or feelings toward stuttering.

But I've actually found... so I use an informal measure of assessing feelings about stuttering and I call it my 10 point stuttering scales. You guys, if you haven't used 10 point scales in therapy, much less stuttering therapy, you are missing out. You get a numerical score for any variable that you could think of that is extremely personalized to your client. And yes, they're "informal and not standardized," but I honestly think that they're the best ones. So what I did is I read through the literature and I picked nine things to rate on a 10 point scale. So that's pretty quick and they ranged from how stuck do you feel when you speak on a 10 point scale with zero being not stuck at all, one being almost never stuck and 10 being stuck all of the time, to how satisfied are you with your speaking abilities on a 10 point scale with zero being not satisfied at all, one being extremely unsatisfied and 10 being perfectly satisfied, to how much do you enjoy speaking to, how frustrated do you get when you talk, to how much does stuttering scare you?

And you can get really good numbers from this that you can see change with treatment. It's the best time saver that I've found to assess these kind of gray, vague and fuzzy things, but still get some kind of a numerical score even if it's not standardized. And on top of those nine things about stuttering, I also asked two questions about their desire to change. Because if they don't have a desire to change and they're seven years old or older, you might as well just not do therapy. So I ask them how much they want to change the way that they communicate on a 10 point scale and then after that I ask, "How hard are you willing to work for that on a 10 point scale?" And if they're like, "I 10 out of 10 want to change the way that I speak and I am willing to work nine out out of 10 hard to get there," then I know they are raring to go for therapy.

If they're like, "I 2 out of 10 want to change the way that I talk and maybe two or three out of 10 want to work hard for it," then maybe now wouldn't it be the best time to get really great outcomes from stuttering therapy. But you can literally assess anything with a 10 point scale. I just picked the ones that see most relevant from the literature and I put them into... so in total it's an 11 question formal self-report rating scale measure that's 11 questions long and I use it all the time and I love it. But of those three things or some kind of configuration of more than one, you should get a pretty good score in some way of their attitudes towards speaking, their feelings towards speaking, kind of their negative impact from speaking. And then I keep it very simple. I ask parents and teachers, I give them maybe a three to four question survey for them to rate on a 10 point scale.

And that just kind of tells me, what do you see? As somebody who talks with this student a lot, lot more than I have, what do you see? So I ask them to rate how severe that the child's stuttering is on a 10 point scale, how frustrated that they get when they talk, how much they participate in or avoid speaking situations in life and then I just ask them, "Is there anything else that you want me to know?" And I take those scores and I kind of average them out and that gives me some kind of a rough guesstimation of how do familiar listeners, what are they seeing on the ground with this client that I can add to what I see whenever I see them for my very short, quick window of time that I see. So that's how I do the last two apps. So we did fluency last week, we did feelings and familiar people this week and then of course you have to tie it up into a bow and make some good recommendations.

Speaker 1: And that's what we get to talk about next week. What a perfect tie-in I love it. So that's a wrap for this week and we'll see you next week to talk recommendations. Thanks for listening to the SLP Now podcast. If you enjoyed this episode, please share with your SLP friends and don't forget to subscribe to the podcast to get the latest episode sent directly to you. See you next time.

Speaker 1: Hello there and welcome to The SLP Now Podcast where we share practical therapy tips and ideas for busy speech-language pathologists. Grab your favorite beverage and sit back as we dive into this week's episode.

Welcome back to The SLP Now Podcast. This week we are continuing the conversation with Stephen Groner, talking all things stuttering assessment. Today, we are diving into assessing speech fluency, but if you missed us last week, be sure to check out that episode because it gave an epic overview of how to start your evaluation. But now, let's chat about assessing speech fluency. Stephen, which tools do you like to use when you're assessing?

Stephen Groner: Yeah, so when it comes to stuttering assessment, there are a lot more tools for assessing speech fluency than assessing the myriad of other stuff that comes with stuttering, so I do think we have some great things to choose from. Probably the one that we're all probably most familiar with will be the Stuttering Severity Instrument, the SSI-4 by Riley and his buddies. That's the one that's most used and it does a pretty good job at assessing simply speech fluency. But I can let you in on a secret and that is you don't need a standardized test to assess speech fluency.

I know you might be saying, "Yeah, but we have to have some kind of a standardized score to qualify students in my district, or qualify them on their insurance," and you would be right. But there is a free standardized measure called the Weighted SLD Severity Score that was published and it's free to use. You don't have to buy any forms, you don't have to buy any manuals. You can use that score and it is a standardized score of speech fluency. Yes, while I have the SSI-4, I have the TOCS. I actually really like the TOCS as well. That's the Test of Childhood Stuttering. It actually is pretty great and it does assess more than just speech fluency. It's a little pricey, which I know can be kind of a deal breaker for some, but I really do like it, and I can talk more about that as well.

But what I tend to use, simply because it's the most efficient and free, is the Weighted SLD Severity Score. But before I could use that, we have to take a disfluency count. Now, disfluency counts in the past have been relied upon as if they are gold, and whatever it says is true about a client stuttering all of the time. That is not true. Stuttering we know is so variable. It can change. I mean, from when I talk to you on this podcast to if my wife were to walk in the door to, if I were to get a call from my mom, my stuttering could change vastly in about three minutes time based off the situation, so disfluency counts are not good, not good at all. Almost worthless. If you only take one in one speaking situation, you might as well throw it in the trash.

But disfluency counts also, I feel like in recent times have been marred of they are not good for anything. You should never take one, they're just so bad, and I don't think that that's true, either. I think if you take a disfluency count of a person who stutters of their stuttering in a number of different contexts, in baseline conversation with you, talking in class to their teacher, talking to their friends at lunch, talking on the playground, as they talk to mom, as they play a game with their sister.

I also love to ask for home video recordings of clients from mom and dad. I say, "Hey, what I see when we meet for your child's assessment, they may have a great day and their stuttering might not seem like what it is to you at home, so if you could send me two or three different recordings of their speech at home that you want me to see, I would love to have that," and boom, you can take a disfluency account from that as well. If you've got three, four, five, six different speech samples, got to have in total at least, at least 300 words or about 500 syllables at least. But I love to go for about three times that. Then you can feel more sure and certain that you have a solid disfluency count.

Then once you have that, that's only one part of your stuttering evaluation, so you need to have an expansive disfluency count for just a small part of your assessment. But on the backside of my one-page stuttering assessment, yes, it's really two pages, but I print mine out front and back, so it's just one sheet on the back, that's where I have my disfluency count sheet.

The way that I do it, and people have all different ways and that is just fine, you find the way that works for you so that you can do it quickly and efficiently 'cause I know that all of our time is limited, but essentially what I do is I have 100-word blocks and I put a dash if the word is fluent and I put a code to say that there has been some kind of a disfluency. My codes are this for stuttering-like disfluencies, so disfluencies that sound like stuttering, I put an "S" if it is a sound syllable repetition. I put a "W" if it is a whole word, repetition, I put an "A" if it's an audible sound prolongation and I put an "I" if it's an inaudible sound prolongation or a block.

If I hear those four, I put that little letter in the slot. Now, you can also have other kinds of disfluencies that don't sound like stuttering, but those of us who stutter can use to slyly mask a true stuck stuttering moment. The ones that I code for are interjects like "likes" and "ums," phrase repetitions where we say a phrase more than one time, or a revision where I think I want to get the chocolate ice cream. Okay, I was getting stuck on "vanilla," so I'll switch it and say "chocolate." I code for those as well.

There was a really great study done back in 2014, Tumanova and colleagues. They found that if you have 8% or more of your words are any kind of disfluency, whether stuttering-like or non-stuttering, then you can be reliably classified as someone who stutters, so if I masked all of my stuttering moments with an "um" or a "like," but I had 8% or more of my words were ums or likes, they found through their cool statistical modeling that you can still say that I have a stutter even if I have no stuttering-like disfluencies, which is pretty cool. I, of course, see if you have 3% or more of your words or 2% or more of your syllables are a stuttering-like disfluency, then that can be a marker for stuttering. Then if your total disfluency count, which is stuttering-like disfluencies plus non-stuttering-like disfluencies, if that's 8% or more, then you can also be reliably classified as someone who stutters.

But I don't just stop there. I have found that I used this next measure a whole lot in assessing treatment success, and that is the average length or duration of a client's stuttering. Now, yes, you probably should sit there with a stopwatch and time every single stutter to be the most reliable, but that is never going to happen in our clinical practices. But I like to make the determination at the end. What was the average length of their stutters? Was it half a second that was more like a full second. Was it a half a second? Was it a full second? Or was it three seconds in length?

You can really see with treatment, say that when somebody came to you, their average stuttering length was three and a half seconds. That is extremely noticeable. Then say that they still have the exact same number of stuttering-like disfluencies, but their average length or duration is now down to half a second. That is going to sound a lot smoother, a lot less stuckness, a lot less struggle. It's going to sound way more forward-moving and you can be sure that something that you've done has helped, even if they have the exact same number of stutters.

I also always do a speech naturalness score on a 10-point scale. Zero is extremely unnatural and 10 is perfectly natural. You can really see some changes there, too, after treatment. It's probably the quickest measure that you could take. Are they, ooh, wow, they had a lot of stuttering, they struggled for a long time with each one? They had so many secondaries, they were probably two out of 10 natural, and then six months later they're like seven or eight out of 10 natural. That is a huge, huge jump. We know if you make a two-point or more movement on a 10-point scale, then you have a clinically significant change, so even going from a two out of 10 when it comes to speech naturalness to a four is a clinically meaningful change, much less seven or eight. Speaking of which, I always list down any secondary behaviors that I see. I don't assign those a numerical score. I just like to list, "I saw a lot of X, Y, and Z," and then we see how that changes.

Okay, so that's my disfluency count, and now is when I would I do the calculation to get their Weighted SLD Severity Score. This is also probably if you are using the SSI-4, it's when you would score it all, and you would see where they fall in the percentiles. But the Weighted SLD Severity Score sounds and looks complex when you first see it, and it can be scary, although once you know it, it's really not.

But one of the things that I made so it wouldn't be so scary is I actually made an online calculator that is inside of my Fluency School Stuttering Toolbox, so if you get that inside of which is also my one-page stuttering assessment, I have a page where all you have to do is put in a couple of numbers, like the number of repetitions in the sample, the average number of how many repetition units that there were, so you could have just one, or you could have two, or you could have three, or you could have four. If you put in the number of repetitions and the average number of units that preceded the affluent word, the number of sound prolongations, whether audible or in audible, and the total number of syllables in the sample, it will spit out a number for you that's either mild, moderate, or severe stuttering, or normal speaking with no stuttering. But you can also do it by hand. That equation is also on the back page of my one-page stuttering assessment.

Essentially, what it is you'll get a score between zero and it can go up to 70, 80, or like 90, but the important thresholds are a score of zero to four is normal, a score of four up to 9.99 is mild stuttering. A score from 10 to 29.99 is moderate stuttering, and anything greater than 30 is severe stuttering. It can go up pretty high. But if you have that number, you have a standardized measure of speech fluency and it is completely free if you want to do it by hand. I love to use that just because it's so ding-dang fast and I don't have time, so I like to use that a lot. It's cool because it takes into account not just how many stutters that there were, but how severe were they are, so if I have a ton of repetitions for each of my repetition stutters, that should be weighted more than if I have just, well, one, right, hence the name: Weighted SLD Severity Score.

Then they also assign, they weight a higher score to prolongations because those do tend to be markers of more severe stuttering. If you're having a lot of prolongations and blocks like that, that tends to be more severe than a repetition, so it weights it based off of what kinds of stuttering that they have, and gives you a standardized numerical score, which I love to use. That's what I tend to use a lot. But you can also use a standardized assessment like the SSI-4 or the TOCS. I really like the TOCS a lot. I used it when I was doing research at Vanderbilt when I was in graduate school. I didn't have it at any of my jobs when I worked 9:00 to 5:00 and I don't have it for my private practice just because the kit costs like $220 and then you have to pay for all the booklets.

But if you can get it, I would choose the TOCS over any other box stuttering assessment kit, if you have the funds for it. What it does is it's so good at walking the child through a number of different speaking situations. They have to name pictures as fast as they can, which can be pretty stressful. They have to say sentences of increasing syntactic complexity, but it's in a structured way, which is really cool. Then it has them do, I think, conversation as well as they have to narrate a story, so you get a lot of different speaking situations all in one.

Then it has some of, in fact, the rating scales that they have inside of the TOCS for parents and teachers are actually what inspired me. That's what I've tried to sort of model my rating scales for that I use because they're so good, so if you have the funding, I would look at the TOCS, at the Test of Childhood Stuttering. But if you don't have it, no sweat. You can assess all of the things that you should for free or very close to it. I hope that was really helpful. I feel like that I lost a few IQ points as I went and I'm sorry. I talk a lot. I say since I stuttered for 17 years, very badly, I like to say that I'm trying to make up for lost time.

Speaker 1: No, that was incredible. What an amazing resource. If an SLT is like, they know that they have a stuttering evaluation coming up, and they feel like they don't know what to do, after listening to you for these 15 minutes or so, they're set. They know what to do.

Stephen Groner: Good.

Speaker 1: Thank you for breaking it down in such a-

Stephen Groner: I'm so glad. You're so welcome.

Speaker 1: ... That's a wrap on our discussion of assessing speech fluency, but we hope to see you next week when we chat about assessing the impact of stuttering.

Stephen Groner: Oh, and really, I love this the most, so I'm pumped to see you there.

Speaker 1: Thanks for listening to The SLP Now Podcast. If you enjoyed this episode, please share with your SLP friends, and don't forget to subscribe to the podcast to get the latest episode sent directly to you. See you next time.