22/07/2021

SPHY304: Fluency
Disorders Across
the Lifespan

Week 2
Using evidence-based practice to guide
assessment
Measuring stuttering and its impact
Early Intervention: when do I treat? Dr Michelle Donaghy

An introduction to paediatric treatments

Michelle Donaghy

ELECTRONIC WARNING NOTICE

SPHY304 Fluency Disorders Across the Lifespan - Dr Michelle

2
Donaghy

In today’s lecture you will….

Use E3BP to guide stuttering assessment

Find out about Stuttering measures: Pros & Cons

Explore contexts of Measurement & Quality of Life

Measures
Paediatric stuttering: Treat or Monitor?

An introduction to paediatric intervention

Michelle Donaghy

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"the complete physical,

1. Tools mental, and
for Assessing social functioning of a person
Stuttering and and not merely the absence
of disease."
its Impact:
ICF and E3BP World Health Organisation
(1946)

Michelle Donaghy

1. The Tools of Assessment:

An E3BP approach

• Look at the external scientific evidence

What science tells us
• Look at the diagnostic evidence
How the disorder presents in the individual
• Look at the evidence before you
What we need to find out about the person as a whole

Michelle Donaghy

EBP & Rationale

Dollaghan, 2007 – ‘E3BP’

External evidence:
Scientific Rigour,
Research

Internal Evidence: Patient

Measurement, Preference:
Dx, Tx Progress, Needs,
Clinical Practice motivation,
supports

NB: There is an E4BP – 4th consideration is clinical expertise ‘Are you trained to carry out this Tx?’☺
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EBP & Rationale

Dollaghan, 2007 – ‘E3BP’ Rationale – Your Clinical Reasoning
Ratify with underlying science
(eg systematic reviews, clinical trials,
External Evidence peer reviewed texts)
Refer to clinical profile
Internal Evidence (Measurement, Dx, Tx progress)

Patient Preference Respond to individual need

(Client/parent/carer preferences,
ability to follow through withTx,
function & participation [!])

Michelle Donaghy

EBP & Rationale

The rationale for your goal has three dimensions as a reflection of E 3BP:

Ratify with science

This assessment has been tested by…..(XYZ, 2017)
This treatment is ‘Gold Standard’ for people with… (XYZ, 2017)
This activity has been shown to…in a similar population (XYZ, 2017)
In this approach, it is important that the client “….’ (p.222, XYZ, 2017)
Taking a case history is important because…(XYZ, 2017)

Refer to clinical profile

(Pt) has been referred because…
In the last session, (Pt) progressed to…so goal
(Pt) has not made progress on measures of…., so change was necessary.
Previous Tx approach of (X) has been unsuccessful/successful for (Pt)

Respond to individual need

Parents were concerned in the previous week that….
New approach was discussed with client owing to difficulties with….
Client and carer expressed satisfaction with progress.
Carer required new strategies to ensure Tx generalising…..

Michelle Donaghy

Stuttering:
ICF and E3BP
Let's use the External evidence to guide our
questions about.....
Internal evidence....
• What is the impairment? (body functions and
structures)
• How does this impact on activity? (limitations)
Patient preference ...
• How does this impact on the
PWS’ participation?
• Do your goals also impact on the
child’s activity and participation?
• How will you measure/assess progress in
all areas?

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• Mostly at age 2 and 3 years, pre-

school age (Reilly et al, 2009)
• Often starts when child puts two words
Assessment and together to make first
‘sentences’ (Bloodstein & Ratner,
Science: 2008)
External evidence • Sudden or gradual onset, sometimes
suddenly severe (Reilly et al, 2009)
• Stuttering at onset may fluctuate over
time, may be context driven – or not!

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Assessment and Science:

External evidence
Stuttering may co-occur with other developmental
disabilities (Boyle et al, 2011)
Treatment is best started between within 12 months
post onset (O’Brian & Onslow, 2011)
Natural recovery is less likely to occur once a child
reaches school age (Lincoln et al, 1996; Koushik et al, 2009)
Treatment outcomes are more variable once a child
reaches school age (Koushik et al, 2009; Andrews et al, 2012)

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Assessment and Science:

External evidence

• Mild repetitions are common

in DISfluent speech
• About 69% of adults who stutter
have a family Hx
of stuttering (Bloodstein & Ratner,
2005)
• A family Hx of stuttering
recovery is a good
sign (Bloodstein & Ratner, 2005)

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Assessment and Science:

External evidence

• Some preschool children may be prone to negative

evaluation of stuttering by their peers (Langevin, Packman
& Onslow, 2009)

• Most parents of preschool CWS report their children

are likely to display some negative reactions to
stuttering* (Langevin, Packman & Onslow, 2010)
• Up to 90% of parents report being affected by
their child’s stuttering (Langevin, Packman & Onslow, 2010)
BUT….preschool CWS are no more likely to suffer from anxiety or negative
self-evaluation than preschool CWNS.

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Assessment and Science:

External evidence

• School children who stutter

encounter negative social,
academic experiences (Daniel,
Gabel & Hughes, 2012)
• ‘...heightened rate of anxiety
disorders’ for CWS (7 – 12
years) compared to non-
stuttering controls (Iverach et al,
2016)
• AWS = 16-34 fold increase
likely of social phobia (Iverach et al,
2009)

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Assessment and Science:

External evidence
• Stuttering can impact on educational attainment
(O’Brian et al, 2011)

• Teachers don’t have adequate knowledge, skills or

strategies to deal with CWS in the classroom (Davidow
et al, 2016).....because

• Teachers aren’t trained about stuttering at university

(Matheson, Arnott & Donaghy, 2018*; Panico et al, 2017)

• AWS report impact on employment, promotion and

performance (Klein & Hood, 2004)

*ACU Honours Graduate SPA Conference Presentation

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World Health Organisation, International Classification of Functioning, Disability and

Health (ICF), 2001

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Stuttering,
ICF, and E3BP
Internal evidence....
• What is the impairment? (body functions
and structures)
• How does this impact on activity?
(limitations)
Patient preference ...
• How does this impact on the
PWS’ participation?
• Do your goals also impact on the
child’s activity and participation?
• How will you measure/assess progress in
all areas?

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Questions for a Case History:

Now it’s YOUR turn!
Points in the 'Assessment and Science' Slides can
be turned into questions
These questions will help you to find out more about
your client's clinical profile (internal evidence) and
your client's needs and preferences .
These questions will provide you with the data for a
Case History.
After the next slide, click on the link provided to the
CASE HISTORY QUESTIONS FORUM and create a
question…

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FORUM RESPONSES REQUIRED!

After the next slide, click on the link provided to the

CASE HISTORY QUESTIONS FORUM and create a
question……

Which state will have the greatest representation

by percentage of responses?

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Will my child recover from stuttering?

Can I wait and See?
• What are the clinical implications of waiting for
recovery?
• Do we Treat? Or Monitor?
• We need to find out about stuttering severity,
frequency and context and stuttering IMPACT
This will be an important focus in the tutorial
this week!

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2. Measurement:
Severity, Frequency, Impact

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Severity Ratings – SRs

Paediatric
• 0-9 scale
• Essential in the Lidcombe Program
• Measured by clients and clinicians
• SR0 = No stuttering, SR1 = Extremely Mild
Stuttering, SR9 = Extremely Severe Stuttering

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Parent SR
Chart
Lidcombe
Program

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Parent SRs – Pros and Cons

PROS
• Parents , with training can use this reliably (Onslow,
Andrews & Costa, 1990; Bridgman et al, 2011)
• Helps to ‘calibrate’ parent severity judgments
• Able to be used over broader periods of time
• As reliable (possibly more so) than %SS (Karimi et al,
2014; Onslow et al, in press)

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Parent SRs – Pros and Cons

CONS

• Does ‘no stuttering’ exist??? SR0 and normal

disfluencies
• There are so many variables in determining SR –
much to the confusion of students speechies!

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Measurement in Practice
• Check with parent what they would normally rate
their child’s stuttering from 0-9 (as in SRs)
• Observe types of stutters
• Take SR in initial conversation (& %SS for >300
syllables – optional)
• Take a baseline SR/SEV at the beginning of
every clinic visit

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Measurement in Practice
• Obtain beyond clinic recordings (optional but
handy!)
• Take a baseline SR/SEV at the beginning of
every visit
• Discuss baseline SR/SEV with parent/PWS
GOAL: Take a baseline SR/SEV at the beginning of every visit
Take a baseline SR/SEV at the beginning of every visit
Take a baseline SR/SEV at the beginning of every visit

Take a baseline SR/SEV at the beginning of every visit

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Severity Ratings – SEV

Older Children & Adults
• 0 - 8 scale* Camperdown Program with
the Fluency Technique (Naturalness)
scale (O’Brian et al , 2017)
• SEV0 = No stuttering,
• SEV 8 = Extremely Severe stuttering

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Severity Ratings – SRs/SEV

Older Children & Adults
PROS
• Enables self- report (Boberg & Kully, 1994)

• Reliability proven between client and SLP,

correlation between %SS and SEV
(O’Brian et al 2004)
• No tools required
• Easy to use ‘online’

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Severity Ratings – SRs/SEV

Older Children & Adults
CONS
• Sometimes there is a difference between the PWS
and SLPs (Ingham and Cordes, 1997a)
• Recent study - poor inter/intra relater reliability for
measuring unfamiliar languages (Hoffman et al, 2014)

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Some things to Consider when

Rating……..
‘There are no generally available training methods to
show inexperienced clinicians what a group of
experienced clinicians believe are representative SR
scores for the clinical population’ (Onslow, 2017)
You: Oh no! I have a severity rating hurdle task in Week 4!

SO how do you learn to rate???

Lots of practice and exposure...
And clinical experience might help...

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Some things to Consider when

using Severity Ratings
• Impact on ability to get the message across
• Listener distractibility
• Types of stutters
• Look for patterns/idiosyncrasies
• Frequency
• Other Considerations?

= How SEVERE is the stutter?

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SR Practice
• Hurdle Task
• SRs and Identify Types of Stutters (MCQ)
Practice with a Friend…
Google ‘Stuttering’ ‘Stammering’
(or ‘Stottern’ [German]; ‘Bégaiement’ [French])
• Identify stutters and rate with a friend or group

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% Syllables Stuttered - %SS

Formula =
Total number of stutters/Total number of syllables X
100 = %SS
SO
IF - $#13 S# 300
13/300 X 100 = 4.33%SS

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Typical Stutter Counter ......

• ADD photo of stutter counter

• iPhone Apps – ‘Fluency Rater’ ‘Disfluency Index
Counter’

Cheap phone apps available. E.g. ‘Disfluency+’

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% Syllables Stuttered - %SS

You can count syllables with a calculator.
Press 1+1 = for the 1st two syllables, then = for following
syllables
You can take a tally of syllables and stutters on a piece of
paper.
Grab a pen and create two columns – one for syllables
not stuttered, and one for syllables stuttered
Or …you can download a cheap stutter counter app for
your phone.

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%SS ACTIVITY!!
Count Syllables:
Ask a family member/housemate what they had for
breakfast.
Take a count of the number of syllables they
produced.
Did you notice any normal disfluencies?
- Interjections
- Repetitions
- Hesitations

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%SS Pros and Cons

PROS
• Straightforward measure of Frequency
• Universally accepted used in research methodology
• Good to have as a baseline (provided you know the
‘Cons’)
• Correlates with Severity Rating Scales (O’Brian et al,
2004)

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%SS Pros and Cons

PROS continued
• Easy for clients to understand (but not to use!)
• Can compare differences between contexts
• Inter-rater reliability for experienced judges
• Inter-rater reliability increases if intra-rater reliability
is good (Cordes, 1994)

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%SS Pros and Cons

CONS (See: Bridgman et al., 2011)
• Contextual discrepancies
• Inter-rater reliability sometimes poor (Kully &
Boberg, 1988; Ingham & Cordes, 1992; Bothe, 2008)
particularly for students (Brundage et al, 2006)
• Doesn’t directly reflect severity
• Too time consuming/impractical for group
therapy (Bridgman et al., 2011; Arnott et al, 2014)

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%SS Pros and Cons

CONS continued
• Doesn’t capture avoidance strategies
• FPs (w/o airflow)in audio recordings?
• Do you count interjections?
• Only counted by the clinician
• What is a stutter? Even experienced
clinicians do no always agree…

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Fluency Technique (Naturalness)

Scales
• Measure of speech naturalness not stuttering (Martin,
Haroldson & Triden, 1984)

• Used in speech restructuring/prolonged speech

therapy
• Camperdown Program (2016) refers to this as the
‘Fluency Technique Scale’ with a 0-8 rating
FT0 = Extremely natural sounding speech
FT8 = Extremely unnatural sounding speech
Previously known as NAT Scale

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Fluency Technique Scale

PROS
• Inter- and Intra-rater reliability in Audio and AV
recordings (Martin & Haroldson, 1992)
• Easy to use by anyone
• Helps to create goals for naturalness when
technique produces ‘unnatural’ speech.
CONS?? – Are there any?

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Syllables per Minute (SPM)

• A measure of pace
• Used in some adult treatments such as 'Smooth Speech'
(Block et al., 2005)

• A 'numerical' approach to measuring level of fluency

technique
• In Smooth Speech: start 60 syllables per minute, aim for
200 syllables per minutes
• Clinician uses a calculator: Press '1' then '+' for every
following syllable for a total
• Stutters aren't counted, so some clinicians see increased
speech rate = sign of improvement

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Syllables per Minute (SPM)

PROS:
• An 'objective' measure – you can count it
• 200 SPM = within the range of 'normal' Australian
speech rate (Block and Killen, 1996)
• Simple tools for the clinician – a timer/stopwatch
and a calculator
• Stutter–counters can also be used to measure this

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Syllables per Minute (SPM)

CONS:
• Requires a clinician to count syllables
• Different people have different speech rates
• Not a functional measure
• Only takes in narrow dimension of severity

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Other Measures
• %WS & WPM - percentage of words
stuttered/words per minute
• SMST – Stutters per Minute of Speaking Time
The future...neurophysiologocial measures?
(Cordes, 2004)

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Other Considerations……
• Making a judgement:
✓Unambiguous stuttering (when in doubt, leave it out!!)
✓Avoidance strategies by the PWS/CWS?

• Varied views on what is defined as stuttering

✓ by parents
✓ by society in general
✓ by health professionals (including Speech Pathologists!!)

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3. Measuring the Impact of

Stuttering

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Anxiety and Distress Scales

SUDs (Subjective Units of Distress)

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Anxiety and Distress Scales

UTBAS (Unhelful Thoughts and Beliefs about
Stuttering)
A scale with 66 items…

BUT … the whole UTBAS may not suit…

so use the UTBAS-6

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OASES (Overall Assessment of the Stutterer's

Experience of Stuttering; Yaruss & Quesal, 2006) - Adult –
School Age
PROS
• Measures client experience of stuttering
• Based on the ICF framework (see Yaruss & Quesal, 2004)
• Helpful when severity is high in some contexts – but not in the
clinic
• Helpful for 'covert' stuttering
• Focus on specific contexts assists with practical goal-setting and
activities
• Strong psychometric properties, established in many countries
• Adult, teenager and school age (7-12 yrs) versions
• Australian normative data (Blumgart, Tran, Yaruss & Craig,
2012).

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Yaruss & Quesal (2004)

Figure 1 Graphic linking ICF (WHO, 2001) to stuttering
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OASES (Overall Assessment of the Stutterer's

Experience of Stuttering)

CONS
• Cost (manual and test forms)
• Time to complete (100 items)
• Measurement of stuttering severity/frequency
still required

https://hrcc.cas.msu.edu/throwback-thursdays/overall-
stuttering.pdf
https://www.stutteringtherapyresources.com/pages/oases

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Canadian Occupational
Performance Measure (COPM)
• An Occupational Therapy tool.
• 'Occupation performance problem' being...
What someone wants to do, or is expected to do
but can't do, doesn't do or isn't satisfied with the way
they do
Assess by semi structured interview to determine:
• Defining the problem
• Client evaluation of performance (1-10)
• Client satifaction of performance (1-10)

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Canadian Occupational Performance Measure

(COPM)
PROS:
• Client-centred
• Focus on functioning and participation
• Provides information useful for collaborative
goal-setting, and useful treatment activities
• Standardised tool: strong psychometric
properties
• Tested on a broad range of clients
(paed/adult)
• Used in interprofessional teams

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Canadian Occupational
Performance Measure (COPM)
CONs:
• While used in Speech Pathology, it has not been
tested in SP
• Useful as a measure of progress in functioning and
participation, does not measure severity of
stuttering in all contexts

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Other Assessment Tools

• KiddyCAT (preschool)
• CAT – Communication Attitude Test (School
age)
• SSI-4 Stuttering Severity Instrument (all
ages)

See Guitar (2014) for a great description of the assessments

above and other useful questionnaires.

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Reporting – Descriptors
Mild – Moderate - Severe

QUESTION:
Parent: How impaired is my child?

Clinician: How do I use descriptor levels for reporting

and diagnosis?

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Reporting – Descriptors
Mild – Moderate - Severe
ANSWER:
- Consider severity (SR/SEV) and take into account
frequency if a reliable count (%SS) and you have
noted the context
- How much would a naïve listener would notice
the stutter?
- How much is the stutter affecting communication?

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Reporting – Descriptors
Mild – Moderate - Severe
Onslow (2021)
SR0 = No stuttering
SR1 = extremely mild
SR2-3 = mild
SR4-5 = moderate
SR6-7 = severe
SR8-9 = extremely severe

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Reporting – Descriptors
Mild – Moderate - Severe
Guitar (2014)

%WS (also relevant for %SS)

• <1% = very mild
• 1-2% = mild
• 2-5% = mild to moderate
• 5-8% = moderate
• 8-12% = moderate-severe
• 12-25% = severe
• >25% = very severe

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4a.
Treat or
Monitor?
When should we start
treatment?

Using the E3BP

Framework to answer a
Clinical Question

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Clinical Questions You Need Answered

• Family Hx of stuttering
• Developmental History
• Communication History
• Consider speech and language skills - assess more
formally if concerned
• How close is the child to school age?

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Clinical Questions You Need Answered

• Time since onset of stuttering

• Pattern since onset
• Stuttering in L1 & L2?
• Has preschool teacher mentioned it?
• Any previous advice or treatment undertaken?

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Clinical Questions You Need Answered

• Child’s reaction to stuttering?

• Parent’s response to stuttering?
• Severity?
• Any perceived patterns in contexts?
• Ask parent to describe stuttering – is it usually like it
is today in the clinic?

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Other Considerations
Observe the child’s behaviour:
• Are they very chatty?
• Are they reticent to initiate conversation?

Barriers to treatment:
• Financial
• Time
• Ability to attend the clinic

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What next?
• Be prepared for Case Studies in your Skills
Class….and….
Duh duh DUHHHHHH….

PEER
SIMULATION
But first…do the Week 2 Quiz
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4b. Evidence Based Early

Stuttering Intervention
An introduction...

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Some Bizarre
examples of Non-EBP in Stuttering

• Pebbles (Demosthenes)
• Burning coal helped Moses (The Talmud)
• Changes in diet, reduced lovemaking - in men
only; and purging (Hyronymus Mercurialis)
• Drink water from a snail shell all your life
(Cameroon)

More can be found at...

http://www.mnsu.edu/comdis/kuster/Infostuttering/folkmyths.ht
ml

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NHMRC Levels of Evidence

• Level I – A Systematic Review
(of level II Studies) e.g. Cochrane Reviews,
Brignell et al. (2020)
• Level II - Randomised control trials
e.g. RCT – Lidcombe Program, J
Jones et al. (2005)

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NHMRC Levels of Evidence

• Level III(1,2)– Psuedo-randomised/

• cohort/case-control trials
• Level III(3) – Comparative Study without controls
• Level IV – Case series
• Then ...Single Case Studies...
• But... can they tell us anything about Stuttering?

NHMRC, (2009)

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Evidence Based Early

Stuttering Intervention
• The Lidcombe Program: "Excellent" (Brignell
et al., 2020)
• RESTART DCM*: "Good" (Brignell et al., 2020)
• The Westmead Program**: Many Level III, IV trials,
one RCT (Trajkovski et al., 2019)
• Parent Child interaction Therapy*: Many Level III, IV
trials

*But there are very few avenues for professional

development for these treatments in Australia
**All studies carried out in Australian populations

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Start Preparing for Assignment One

Paediatric Stuttering Case Study
Watch out for announcements on signing up to a simulation group on
LEO under ‘Assessments’

• Early Intervention - Lidcombe Program

• Session Plan
• Progress Notes
• Simulation Scenarios

Mandatory Reading:
The Lidcombe Program Guide

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