Adult stuttering Ax
Process
Gathering data from client
Getting to know the client as an indv
Showing an unds of the client's POV
Demonstrating unds of stuttering
Getting to know key fam members-recognise where boundaries are. Rapport building
Fluency Ax is an ongoing process: conversational samples, %SS, severity ratings
Things to be mindful of
Clients' needs
Clients' right to privacy
Be careful about referral info, past experiences and biases--> might cloud ability to see all aspects clearly
Ask qns, observe, explore situations before deciding how to help
X give false expectations, X make promises you can't keep. Recognise that adolescent, adult, may not have access, some want quick fix. Assuming that by atttending Tx, stutter will go away. Cannot promise them that
Build up trust to make changes that you mutually decide are appropriate
Client needs to be able to trust you to protect their privacy
Confidentiality: impt element of client-clinician r/s
Clinicians need to familiarise themselves w content documentation for audio, video recordings. Let clients know that it will be good for their learning. But recognise that some of them don't want to be known by other ppl
Info that they disclose to you may be diff from what they disclosed to their parents: their rights to privacy, nature of info, if anything is harmful, then we have to intervene. Tricky when they are telling you personal info about their parents.
Eg. adolescent male, diff to involve in Tx, mom used to drop him off at clinic, opened up about what was happening at home. Dad would imitate his stutter. Demoralising, favoured his sibling more than him, comfortable about talking about mom. Provide mom education about stuttering. Don't blame dad. Mom would be taught to implement some strategies
Cultural considerations
Dev. multicultural perspective on Ax, Tx
Be aware, sensitive of diff in comm styles, how other cultures view S&L disorders, touch and invasion of personal space, praise (to develop special signal b/w parents and children to reinforce fluent speech but do they prefer doing high 5 or clapping?). Slow down speaking rate is considered unnatural and difficult to sustain- operant conditioning may be more appropriate
Bilingualism
Stut may viewed negatively, client X have same intelligence as others. Provide education around stut.
Need to identify stuttering vs limited proficiency in 2nd lang
Increased risk of stut in biling indv
Need to observe if there is presence of secondary behaviours, cognitive, emotional response to stut
Although stut may occur in one or both lang, more likely to happen in both
May be more severe in one lang BUT need to analyse stut in both lang to determine Tx plan. Decide if you will provide Tx in one or both lang
Need interpreter, family member to provide you w info, regarding stut in native lang
What to ask in Ax?
Freq
Type
Duration
Secondary behaviours
Severity
Fluency techniques, speech naturalness
Speech rate
%SS
highly correlated w severity, BUT X reflect duration or physical tension associated w stutter
Research suggests that %SS is not a reliable measure but still clinically relevant. NOTE: maintain consistency in your use of %SS
Stut identification
What does the profile look like: primary, secondary, non-verbal, verbal.
Measure duration of longest prolongation/block to determine how much stut is hindering comm.
Use as part of complete Ax of severity in SSI-4
Trying to help them push through. Hope that this will reduce over the weeks.
Escape behaviours used to break out once stutter has started
May also be avoidance behaviour to prevent the stutter
Eye-blinking, extra sounds, pitch rise, tapping, shaking their legs
Indicate stutter has progressed into more advanced stage
Most clinically relevant Ax
Reflects overall impression that listeners may have of a PWS
Impt measure of assessing treatment outcome
Measure of progress during Tx: Aim to reduce severity rather than eliminate
Eg. SSI 4
Stut severity scale eg. Camperdown
most commonly used, reliable measure of stuttering severity, analyse w/i, beyond clinic samples for pre-post measures, quantifies stuttering, evaluates effectiveness of Tx. Ages 2;10-adults, Testing time 15-20min, normative data
Frequency: %Ss in normal speech, duration average length of 3 longest stuttering w/i clinic and beyond clinic(bcos env factors may make them nervous). Physical concomitants distracting sounds, facial grimaces, head mvms, arm, leg mvm
Naturalness of speech, number translates to severity (mild, moderate, severity) recordings of convos
Why use?
Common lang b/w SLP and client
Simple to use
No equipment
Portable
Non-intrusive
Clients can self-monitor and report
Evidence for
Perceptive measure vs. objective
Valid
Reliable
Limited training
Correlates well w %SS or severity
Limitations
X account for stut type
X account for word avoidance
X account for situation avoidance
X account for anxiety
So need to incorporate these into discussion to find out more abt severity ratings
To ask ourselves:
Was there any stuttering, if no, need to assign SR0
Would it be heard by a casual observer? If no, then SR 1
How much does it interfere w communication?
Was it mild, moderate or severe?
Camperdown program
Breakdown of scoring
0: Natural sounding speech w no fluency technique used
1: Natural sounding speech w minimal fluency technique used to control stuttering, prob not obvious to any listener
2: Natural sounding speech w some fluency technique being used to control stut, prob obvious to familiar listener
3: fluency technique will be obvious enough to be noticed by an unfamiliar listener
4-5: Useful lvl for clients to practise fluency technique in clinic env
6-8: Exaggerated fluency technique, similar to training model. Typically eliminates all stuttering and is useful for practising fluency technique, unlikely that client would be comfortable using this in everyday situations
To tone down: I am hearing too much of technique but I need more Charlie. Rmb the water to cordial analogy
SPM: total number of syllables/time in seconds x 60
Count only syllables that would have been said if they did not stutter. Only those that convey info to listener
Communication vs. articulation
Communication rate
Speech/articulation rate
Person communicates w stut behaviour
Let stopwatch run during the stuttering moment
What the person is capable of without stutter
Turn stopwatch off when stutter occurs
During the stut moment, communication rate is LESS than articulation rate
WE ARE INTERESTED IN THIS!
The flow
Questionnaire: case Hx of general, fluency specific, problems related to stut.: Ask them to say their name bcos this is what they stutter on. Tell them "I needed to hear it". Ask them to list days of the week, repeat after clinician, prolongation of ah (need to hear if there is tension or click in the VFs), DDK for motor planning
Modified Erikson scale (meant to be icebreaker, don't read them aloud. Let's talk through some of those that you are unsure about. Don't overthink them! PWS will have range 9 to 24, mean 19. Ppl without stutter range 1-21, mean is 9
Conversation sample 5-10min, record whole session after consent, 5-10min of client talking, 600-1000 syllables. Analyse according to SR chart, SSI-4
Reading sample: mix up the passages, dont repeat! Measure SPM and %SS
Beyond clinic measures
Locus of control:
Self-rating of rxns to situations: Ax client's tendency to avoid specific speaking situations
Hierarchy of difficult situations: ranking 10 situations
OASES (overall Ax of speaker's experience of stuttering)
Further Ax: S&L-voice-pragmatics Ax, Liebowitz social anxiety scale (LSAS)
Degree to which person perceives causal r/s b/w their own behaviour and consequences. Extent to which client believes they can control their own behaviour. Theory that suggest gauge of indv's attitude to their env. Consider cognitive restructuring if they have external locus of control
Internal: feels in control of their env, able to affect outcomes or events through their own actions, efforts, r/s b/w outcome and response is perceived to be result of personal effort or ability. This lowers the score shows they are able to take control of stutter
External: somebody who feels that stutter is fated, always happen to them, push the blame to others and the env, unable to exert influence over their destiny
Ax impact of stut on person's life, based on ICF
used for client to unds disorder of stuttering and its impact
Age range 7-18+
15-20min
Each qn on Likert scale 1-5
Benefits
Quick, easy self-Ax
Can pick and choose which one is relevant
Enables insight beyond numerical stuttering severity rating
Helps unds complexity of stuttering condition
Allows you to evaluate speaker's perceptions about stuttering, speaker's rxns to stuttering, difficulties w everyday activities that involve comm.
Able to examine functional comm. difficulties, QOL for those who stutter
Promotes self-awareness on how stut affects life, sch, work, home, social settings
Stut caused by
Instability in speech motor control system
System's response to this instability
Interactions b/w 2 loops: Stut occurs when there is mismatch in inner loop (programs and monitors sounds being made) vs. outer loop (provides reasoning, choice of words being said)
We are dealing w chronic group so that system is not likely to change, going to remain unstable but we still want to stabilise that system