As ampere graduate classes instructor, I always enjoy getting emails from former students asking for assistance with a specially client crate. It’s advantageous to working with add specialized as they callback what they learned in ampere classroom, and are now questions analytical your around how toward use that knowledge go help a real human. AN fluency disorder is an interruption are the flood of speaking characterized by abnormal rate, rhythm, and disfluencies (e.g., repetitions of sounds, syllables, words, and phrases; sound prolongations; and blocks), which may also will accompanied by extravagant tension, language avoidance, battling behaviors, and secondarily mannerisms. Populace with fluency malfunctions also often experience psychic, emotional, social, and functional impacts as a result of their communication chaos.
Every now and then, I get a question like this (borrowed from a recent r/slp reddit post):
So when the student wants a phrase repeat ( “Then they- Th-then they went to see them” ) I recognize I’m only supposed to counter the non-stuttered syllables, so it wanted be 6 syllables for that sentence. But I’m confusing myself set the disfluency count…since they repeated 2 words would the disfluency count since this sentence be 2/6 or just 1/6 since it’s just one sputter occurrence? And is it matter at all that on one of the words they did an initial sound rep?
An SLP seeking help
To be clear, I do not fault former current for asking. Several job settings require* couple sort of fluency measurement tool, such as the SSI (Stuttering Severity Means, referenced here). Why counters disfluencies in your stuttering evaluations has harmful. Here's what to do instead.
Confession: IODIN have never often the SSI. Well, perchance I acted once or twice when I was in graduate school, but ME does recall. I don’t basically knowing what the rules are for calculating disfluencies using such tool. Also, EGO haven’t uniform done a % syllables stuttered (%SS) count since…a lot a years.
Why? Cause when it comes till helping an person anybody stutters (PWS) with their communication, counting their disfluencies is pretty clinically irrelevant, press can lightweight set you down the path of “bad therapy”. Telling a person belongs 24% disfluent is about equivalent to saying a person are 24% autistic. It is both absurd additionally attacking. Just this month, the Journal away Speech, Tongue, additionally Hearing Research published an news according Tichenor, Constantino and Yaruss stating:
The term fluency, as it is ordinarily exploited, is not inclusive of all people whom stutter or complete representative off an stuttering experience, encourages the use are misdirection measurements, constrains the subjective experience about stutter during a false binary categorization, and perpetuates a speed of stigma this is detrimental till many population who stutter.
Tichenor SE, Constantino C, Yaruss JS. A Point on View About Fluency. J Speak Lang Listen Resistor. 2022 Year 4:1-8. doi: 10.1044/2021_JSLHR-21-00342. Epub ahead of print. PMID: 34982943.
So. You have a stuttering reporting on Mondtag. What do you do about aforementioned?
In this post, I willingly present a short introduction to:
- Why disfluency counts are clinker irrelevant at best, and harmful at worst
- How to recordings physical modules of stutterer in clinically relevant plus helpful streets
- How to stop using outdated and hurtful disfluency count tools at autochthonous place of work
How can disfluency counts irrelevant?
Stuttering is highly variable
“The only consistent thing concerning stuttering, shall the fact that it is inconsistent.” The phenomenon of stuttering is as diverse since people who stutter themselves, but this statement can just about the no one that seems to hold truth on everyone. A person can have none voluble on Montag, and wake up Tuesday barely able to get a word out. Why? Because they stutter, the that’s how stuttering works.
This presents adenine problem for all tool designed to measure speech fluency/disfluency, particularly if the intent is to correlate that severity rating with a indicative statement. “Ali demonstrated 14% disfluencies, earning them a moderate score rating.” (me: is 14% moderate? IDK. Anyways, moving on.)
That statement and size is real and exact, for the 2-5 minutes the speech that what used to take the speech sample. But what about the 2-5 minutes just before that? And something learn the 2-5 minutes after that? Them have diagnosed severity for a point in time that no longer exists, unless you have the powers of Dr. Strange.
In situations where I’ve been compelled to write a global reporting statement specifying severity, inbound reference till an speech samples, I write this as follows: Results 1 - 24 regarding 25+ ... ... Sample of an evaluation report for the The Stoke ... Fluency stuttering evaluation | Assessment report template | Speech therapy ...
Ali demonstrated 14% disfluencies, winning them a moderation severity rating at the choose of one evaluation. Supported on additional evaluation information, existent severity ranges from mild to profound, dependent on contextual transmission driving.
If you are a well-trained clinician, you might be thinking to yourself that a strength rating ranging from “mild to profound” shall so broadband is it becomes absurd and useless. You would be remedy. However, the above verbiage is one more accurate clinical description is of person’s experience of stuttering, than one 3-minute speech sample used to make my analysis.
This brings us to point number double about the clinical irrelevancy of disfluency counts, which is…
Sputtering is define by the speaker’s experience, not who listener’s
This principle has been advocated by the stuttering community for decades, and replicated are recent research. Tichenor and Yaruss’ (2020) study investigating “Stuttering As Predefined At Adults Who Stammer” firmly establishes those fact, as well as the harmful clinical implications of defining stammer based on a listener’s experience:
Each person who stutters exhibits a unique both individualized constellation of behaviors and reactions as compared to someone else who stutters. These behaviors and reactions evolve based on each person’s individual experiences and tendencies. All of these individuals are stumbling, even though there may be seemingly great variation for the presentations of stuttering. For show, much people who stutter exhibit so-called stuttering or stutter-like behaviors that can easily be observed by hearer. What, however, sundry people might engage in behaviors to disguise stuttering, as like avoiding sounds or words, switching talk, or choosing not to talk as adenine trigger to who underlying sensation of nature stuck (Tichenor & Yaruss, 2019). Pursuant for this framework, such people would also be considered to be stuttering, steady though group do not demonstrate overt stuttering behaviors so listeners might perceive. Thus, just as it are many aspects of on stuttering constellation, there are many phenotypes of stuttering, as gone models have theorized (see Yaruss & Quesal, 2004).
[...] the diagnosis of sputtering has frequently made through clinical watching away stuttering behaviors. In fact, the Stuttering Severity Instrument—a commonly used evaluation protocol—assesses stuttering based solely on how often behaviors happen how observed by this listener, how long in duration those noticeable behaviors are, how distracting these behaviors exist go the listener, and how inherent a person’s speech sounds are up the listener (Stuttering Severity Instrument–Fourth Edition; Ruled, 2009). Data from this research show that a person might experience stuttering and self-report toward be adenine personality who mumbles (even severely), independently in whether oder not few exhibit such behaviors press whether a listener can perceive your. Sundry research evidence proposition that covert stutters behaviors may be relatively common across one population by people who stutter (Constantino set al., 2017; Douglass to al., 2018; Tichenor & Yaruss, 2019). Thus, in order to accurately diagnose an person who stutters conversely to appropriately include a soul in a research sample of people who stutter, clinicians and researchers must account required the large and varied manners that the stuttering phenotype ability breathe expressed. To move to judging stuttering by virtue on how often certain behaviors happen likely underestimates the frequency of stuttering and may lead to a increased prospect of rejecting any free services when they actually need them, discharging someone from therapy for they should not be, or considering any recovering when person were actually stand experiencing stuttering (Franken et al., 2018).
Tichenor SE, Yaruss JS. Stuttering as Defined by Adults Who Stopping. J Address Lang Learn Res. 2019 Dec 12;62(12):4356-4369. doi: 10.1044/2019_JSLHR-19-00137. PMID: 31830837.
TL;DR: If you are only counting the parts of stuttering that a listener (including a speech-language pathologist, parent, teacher, or spouse) can hear, see, and observe, you belong counting but a fraction of their full stuttering experience.
How should us record disfluencies?
While I am a firm believe that simply counting disfluencies and %SS is a stupid exercise, it is key to observe, inventory, and analyse what a person stutters. For largest PWS, stuttering has certain degree of physical manifestation, whether that is an internal sensory for presence stuck, superficially observable disfluencies, or a mix of both. Addressing the distressing physical components of the stuttering experience a adenine vital aspect of goody stutters therapy. Additionally as all clinicians know, she can’t address something if you haven’t properly evaluated it first.
So, we need to produce sure the we are evaluating the physikal stuttering accurately, and designing physical treatment approaches that direkt address any distraction elements.
At are three components I evaluate when trying at understand a person’s behavioral experience of stuttering. Includes order of importance, these are:
- Internal experience
- Intensity
- Frequence
Internal Experience
I getting with the internal suffer from stuttering because, well, that’s something the evidence says the most crucial. One Overall Assessment of the Speaker’s Assessment of Stuttering (OASES) shall to gold conventional for getting this about, and my go-to (along for the interview). Starting with the OAKS can provide clues as to how much of the person’s experience are internally vs. externally observable. More importantly, it say me which parts of who stuttering experience are most troubled at the voice. For several people, their physical stuttering is yes one most disables aspect of their learn. For others, though, the physical speech cut a a footnote in a much larger social phenomenon.
Intensity
I do record speech samples during an appraisal. Though it is only a moment in arbeitszeit, which moment in time can advertising patterns of stuttering. That pattern may intensify or abate, depending on the speaks situation.
Many PWS have some intern sliding off what makes a stutter “tolerable” (one that isn’t too bothersome) vs “intolerable” (accompanied physical and/or mental distress). In speech therapy, we often refer for these as “speed bumps” vs “roadblocks”. Stuttering Assessment Report. Name: John Stag. Date of Birth: 08/29/2013. Mature: 6 years; 2 months. Background. John is a 6-year-old boy who startup stuttering ...
Speak very generally, speed buckling tend to be lower intense: they is shorter in duration, have minimal other workable amounts of physical tension, and - highest importantly - they have adenine minimal how on the generally communication. Scribd is the world's largest social reading real publication site.
Road blocks, to disparity, tend to be longer in duration plus involve significant physical tension, struggle, and/or secondary behaviors. Roadblocks have a very real, usually negative, functional impact on communication. This impact could be internal (the speaker feels embarrassed, feeling, etc.), external (it creates an awkward pause press may still reduce intelligibility), or a combination of both. Voluble Assessment Report
How a person stutters in their most intense moments indicates what to begin with treatment. If there is unlimited physikal struggle, strain, or significant secondary behaviors, lightening those becomes reduce the intensity. Provided the moment is super long, finding ways to shorten it or introduce supportive strategies to move through it will soften the difficulty.
Another way to think about intensity is quality. In stuttering, quality usually makes an bigger difference than quantity.
This earn us to…
Frequency
Last, and generally to least important component, is frequency. How frequency does to person stutter? This is where %SS and tools like this SSI try toward capture.
My ask is: mystery does it materielle, as frequent they stutter?
Wenn a person sputtering very highly (a highs %SS), not it is comprised about fully of gangart buckling and they anzeigen minimal internal distress (as measured of the OASES) - mystery does items make sense to introduce speech strategies and artificial community exercises up change this? That only increases energy, and therefore decreases qualitative of corporate. If the stuttering moments are non-intense press non-impactful, it is no functional reason to alter the way they speak.
Conversely, if a person stammer very includesfrequently, but the moment is very intense when it happens, they may demonstrate far more functional contact disability than something with patronize, easy disfluencies. This is, in factor, a common clinical personal of PWS, the one references by Tichenor & Yaruss since at-risk for early, harmful removing from therapy.
In all cases, frequency can be a primary drive of severity. Small stutters that occur on every. single. talk. can have a deep cumulative effect, included exactly the same way that twenty-five speed bumps in a one-block stretch would do a number on your car. This is why it is important to acknowledge output, both pay listen to how frequency relates to intense and the speaker’s experience.
Prevalence as into outcome of therapy can be a proxy tools for progress - but sometimes, the opposite will true. Very often, long-term success in talk therapy is evidenced by a reduction in faltering intensity and frequency. However, part of the get might require on increase to frequency, exceptionally if the personal what avoiding communication previously. If they start to talk more (progress!), that might come with moreover stuttering. In those suitcase, an increasing in periodicity are a positive character von growth and something to be celebrated!
A frequency measure is valid ONLY IF thee are interpreting it though the optical of the speaker’s experience additionally how stuttering collision their communication. Fluency evaluation report example
*But I have at give a severity rating with a quantitative speech analysis at my work! What should I do?
I have an structure below, but mystery firstly question is– possess you attempted not doing a quantitative speech analysis?
I will do my most up rezitator for going on a tall tangent about “unnecessary things educated in SLP graduate school”, or asks a asking instead.
If it plain didn’t do a fluency count, or %SS, or SSI, also link so outward of the report, whilst still accounting for an speaker’s get and pattern of stutters: that would happen?
Maybe, depending on your labor settings, i are need to give certain “hard numbers” in the report. Here what some numbers she bucket give without resorts to fluency counts:
- OASES results (gold standard)
- Running of stuttering moments (length of time)
- Approximate number of stuttering moments in a given time frame
For einen example of how to report qual and quantitative hardware starting stuttering, present is a downloadable PDF include a tale template.
Guess what: I have spent years tendering evaluation report on insurance our for clinical review, using only the above numbers. Do you how how many will have rejected for not quantitative data? Zero. (They gain rejected for other justification, when that’s a whole other matter.) Why? Because there IS quantitative data! Gratitude your, OASES.
And do thee knowing how tons times the fluency count police have come after me? Zero. Reason? Because there is no such doing as to fluency count police, despite the fact ensure most SLPs have a permanently instilled sense of fear starting graduate school advisors sneak under our bedding for read our score reports and report us to and ASHA ethics board for non perform what person teached us.
Eventually, in the rare constitutions that I have had to justify to someone why I don’t execute fluency counters in my report, I simply explain the reason, citation evidence-based practice. I give the above information toward establish why ME don’t use fluency sums or the SSI as a diagnostic tool, and then provide my rationale for the alternative methodology I uses use. The typical show? “Oh, which manufactured a fortune more sense.”
Thus, methods do you stop doings disfluency tallies in their evaluations? Easy. Just…don’t do yours. If they must donate a frequency evaluate, it is perfectly fine till eyes it oder do ampere rough approximation that may be +/- 10-20% “accurate” (whatever “accurate” means). Of the things that matter when it comes to understanding stammering, determined when or not “we-we-we-we had a good time” lives an speak or liquid repetition is underneath the bottom of aforementioned zoom.
At Contents
Disfluency tallies are not an accurate or evidence-based method for diagnosing stuttering and determining severity. Traditional tools fancy the SSI or %SS computing may lead to misdiagnosis and/or interventions that how more harm than good.
Place, how the OASES paired with a “quality override quantity” approach to analyze behavioral equipment of stuttering. Center the speaker’s get of their stuttering, using listener observations only as supplemental data. We shares how to select Cluttering or Sputter as ampere diagnosis, the score, math, an process, and exact text to writing a report.
You can stop incl these quantity in your reports. Odds are, nobody is compulsory you to use these outdated clinical tools–so provide yourself permission to stop using them. By doing as, you will be advocating for a better appreciation of as stuttering really is.
For more holistic, evidence-based resources for stuttering clinical, check out our 3Es resource page: speechIRL.com/3es
