Assessment section of the Fluency (Children) Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Individuals suspected of having a fluency disorder are referred to a speech-language pathologist (SLP) for a comprehensive assessment. A thorough assessment focuses on components known to accompany fluency disorders (e.g., affective, behavioral, cognitive, and others). Assessment is individualized and based on the person's communication environment. Cluttering and stuttering do not need to occur in all situations or even a majority of the time to be diagnosable disorders. Furthermore, some children may use secondary behaviors, such as substituting or omitting words or circumlocution, as a way to hide stuttering symptoms (Murphy, Quesal, & Gulker, 2007).
Symptoms and severity of stuttering and cluttering can vary across situations (Conture, 2001; St. Louis & Schulte, 2011). Therefore, it is important to collect samples of speech across various situations and tasks, both inside and outside the clinic, in order to have an accurate evaluation (Yaruss, 1997). For example, cluttering symptoms have been known to normalize during a formal evaluation of speech, due to increased self-monitoring. Symptoms of cluttering often are observed more frequently in situations where the individual is more comfortable and therefore less likely to monitor speech production. On the other hand, stuttering may decrease if an individual is more comfortable.
A speech and language assessment is indicated when one or more of the following are observed in conjunction with disfluencies. This is not an exhaustive list, and any factor may initiate a referral. Not all of the characteristics need to be present (e.g., Guitar, 2013; Yaruss, et al., 1998).
- There a family history of stuttering or cluttering.
- The child exhibits any negative reactions toward his or her disfluency.
- The child exhibits physical tension or secondary behaviors (e.g., eye blinking, head nodding, etc.) associated with disfluency.
- Other speech or language concerns are also present.
- The child is experiencing negative reactions from family members or peers.
- The child is having difficulty communicating his or her message in an efficient, effective manner.
- There is parental concern.
A comprehensive assessment is sensitive to cultural and linguistic factors and addresses the components within the World Health Organization's (WHO) International Classification of Functioning (ICF) Framework (ASHA, 2007; Coleman & Yaruss, 2014; Yaruss, 2007; Yaruss & Quesal, 2004, 2006). See
assessment of fluency disorders in the context of the WHO ICF framework.
A comprehensive assessment typically includes
- relevant case history, including
- medical history;
- general development;
- speech and language development, including frequency of exposure to all languages used by the child and the child's proficiency in understanding and expressing himself/herself in all languages spoken;
- family history of stuttering or cluttering;
- description of characteristics of disfluency and rating of severity;
- age of onset of disfluency and patterns of disfluency since onset (e.g., continuous or variable) and other speech and language concerns;
- previous treatment experiences and treatment outcomes;
- information regarding family, personal, and cultural perception of fluency;
- consultation with family members, educators, and other professionals, including their observations of fluency variability (when disfluencies are noticed most and least) and impact of disfluency;
- real-time analysis or analysis based on review of a taped speech sample, if provided by a parent or teacher, demonstrating representative disfluencies beyond the clinic setting;
- review of previous evaluations and educational records;
- assessment of speech fluency (e.g., frequency, type, and duration of disfluencies; presence of secondary behaviors; speech rate; and intelligibility) in a variety of speaking tasks (e.g., conversational and narrative contexts);
- stimulability testing in which the child is asked to increase pausing and/or decrease speech rate in some other way-a reduction of overall rate of speech typically assists with a reduction in cluttering symptoms;
- assessment of the impact of stuttering or cluttering-including assessment of the emotional, cognitive, and attitudinal impact of disfluency-for information concerning speaking frequency and socialization;
- assessment of other communication dimensions, including speech sound production, receptive and expressive language development, pragmatic language, voice, hearing, and oral-motor function/structure;
- determination of individual strengths, coping strategies, and available resources that may facilitate the treatment process.
Assessment may result in
- diagnosis of a fluency disorder, including differential diagnosis of type of fluency disorder (stuttering, cluttering, or both) and between fluency disorder and reading disorders, language disorders, and/or speech sound disorders;
- descriptions of the characteristics and severity of the fluency disorder;
- judgments on the degree of impact the fluency disorder has on verbal communication and quality of life;
- determination if the child will benefit from treatment;
- determination of adverse educational, social, and vocational impact;
- recommendations for treatment;
- consultation with and referral to other professionals as needed;
- ongoing education about stuttering or cluttering for family, school personnel, and other significant people in the child's environment.
assessment procedures: parallel with CPT codes for a breakout of pre-evaluation, intra-service, and post-service procedures.
Special Considerations: Assessment of Preschool Children
The purpose of assessing fluency in a preschool child is to determine
- if a child has typical disfluencies or a fluency disorder (see
characteristics of typical disfluency and stuttering),
- if the child is likely to recover without treatment (i.e, exhibit unassisted or spontaneous recovery),
- if monitoring or treatment is required.
If treatment is warranted, it is necessary to determine the timing for intervention and to set out a plan for parent education and counseling. If treatment is currently not warranted, the family is educated about how to monitor the child's speech to determine if and when the child should be reevaluated.
For stuttering, the assessment will identify risk factors associated with stuttering, severity of stuttering, and the presence of other speech and language concerns.
Although cluttering has been reported in children as young as 4 years of age, the diagnosis is more commonly made at about 8 years of age (Ward, 2006), when a child's language becomes lengthy and/or complex enough for symptoms to manifest themselves.
Special Considerations: Assessment of School-Age Children and Adolescents
The purpose of assessing school-age children and adolescents is to determine the presence, extent, and, most importantly, the impact of the fluency disorder and the potential benefit from treatment. As children who stutter get older, they may become adept at word and situational avoidances that may result in a low frequency of overt stuttering. In addition, children with cluttering or stuttering may only experience symptoms situationally. However, despite the fact that some children may show little observable disfluency, they may still be in need of treatment for a fluency disorder because of the negative effect that stuttering or cluttering is having on their lives.
Special Considerations: Assessment of English Language Learners
Bilingual children are assessed in both languages to observe whether stuttering occurs in both (Finn & Cordes, 1997). Clinicians familiarize themselves with the languages spoken with the child and collaborate with an interpreter as necessary. See
bilingual service delivery and
collaborating with interpreters.
Bilingual children who stutter typically do so in both languages (Nwokah, 1988; Van Borsel et al., 2001). There is not a great deal of information about whether bilingual individuals who stutter are more disfluent in one language than the other (Tellis & Tellis, 2003), although many bilingual individuals who stutter report this to be the case (Nwokah, 1988). Differences in fluency across languages may be due to the social context in which the language is used (Foote, 2013), as well as the level of development of each language spoken.
Moments of stuttering or disfluency may be difficult to differentiate from instances of typical disfluency or reduced language proficiency in English language learners (ELLs) for a person unfamiliar with the language (Shenker, 2011). Increased accuracy and reliability of judging unambiguous stuttering may be achieved by enlisting the help of a person familiar with the language and rating fluency in short intervals of speech to reach consensus (Shenker, 2011). Parents of bilingual children easily can be trained to provide perceptual ratings of fluency in any language spoken by the child (Shenker, 2013). Parents may also note if secondary behaviors of disfluency are present in both languages.
As is the case with any communication disorder, language differences and family/individual values and preferences are to be taken into consideration during assessment. Languages differ with regard to developmental milestones, and direct comparison of scores across languages can be misleading, even if the assessments appear similar (Thordardottir, 2006). It is not appropriate to determine a standard score if the norming sample of the assessment is not representative of the individual being assessed.
Differentiating between typical disfluencies and stuttering (i.e., ambiguous and unambiguous moments of stuttering) is a critical piece of assessment, particularly for preschool children (see
characteristics of typical disfluency and stuttering). For school-age children, it is important to distinguish stuttering from other possible diagnoses (e.g., language formulation difficulties, cluttering, and reading disorders) and to distinguish cluttering from language-related difficulties (e.g., word finding and organization of discourse) and other disorders that have an impact on speech intelligibility (e.g., apraxia of speech and other speech sound disorders). It is important to note that children may have fluency disorders as well as co-occurring conditions.
Disfluencies noted in bilingual children are similar to those found for monolingual children (Shenker 2013). Mis- and over-identification of stuttering in bilingual children may occur due to typical disfluencies observed in development, code switching, and wording changes in order to maintain the grammatical integrity of the dominant language. However, these disfluencies are typical and not indicative of a disorder (Shenker, 2013). Tellis and Tellis (2003) caution clinicians that they should not confuse word-finding problems in the second language with stuttering for ELL children.
Although cluttering and stuttering can co-occur, there are some important distinctions between the two (see
Scaler Scott, 2010). Children who stutter are more likely to be self-aware about their disfluencies and communication, and they may exhibit more physical tension, secondary behaviors, and negative reactions to communication. Children who clutter may exhibit more errors related to reduced speech intelligibility secondary to rapid rate of speech.
Although school-age children with reading disorders may exhibit difficulties with oral reading fluency, there are likely to be differences when compared to children who stutter. Children who stutter may exhibit
- increased disfluency rates in reading tasks (decreased reading fluency), because they cannot change the words to avoid moments of stuttering as easily as they can in conversation;
- disfluencies with physical tension and secondary behaviors.
Children who stutter typically know how to read the printed form of the word; they just cannot speak the printed form fluently. In contrast, children with reading disorders are likely to have difficulty with decoding the printed form (Kuhn & Stahl, 2003).
Oral reading measures may not be valid for children who stutter, as fluency breakdowns will slow reading rate. Reading slowly may be perceived as a reading problem, even though the underlying cause is disfluency. The validity of reading assessment tools for children who stutter is questionable, because it is difficult to differentiate the cause (decoding or stuttering) of oral reading fluency problems. Alternative measures of reading fluency, such as tests of silent reading fluency, may be more valid measures for children who stutter. See an article by
ASHA's Ad Hoc Committee on Reading Fluency for School-Age Children Who Stutter.
When assessing reading fluency in a bilingual child, it may be difficult to determine the linguistic complexity of a text in a language unfamiliar to the clinician. Clinicians need to avoid using religious or highly familiar texts that children may know by rote (Foote, 2013).
Fluency Disorders/Language Difficulties
Children with language difficulties at the sentence, narrative, or conversational discourse level may exhibit increased speech disfluencies, particularly interjections, revisions, and phrase repetitions. However, their disfluencies are not likely to involve prolongations, blocks, physical tension, or secondary behaviors that are more typical for children who stutter (Boscolo, Ratner, & Rescorla, 2002).
Word-finding issues can create increased non-stutter like disfluencies that are similar to those observed in cluttering; specific standardized tests can be used to rule out word-finding difficulties. Assessing organization of discourse also can help rule out verbal organization issues that might be mistaken for cluttering (van Zaalen-Op't Hof, Wijnen, & Dejonckere, 2009).
Cluttering/Other Disorders of Speech Intelligibility
Other disorders, such as apraxia of speech and/or articulation or phonological disorders, can affect speech intelligibility; standardized tests can be used to rule out these causes of reduced speech intelligibility.
When determining eligibility for speech and language services, speech-language pathologists need to document the "adverse educational impact" of a disability. This includes the impact on functional communication in key school situations and on quality of life (Beilby, Byrnes, Yaruss, 2012; Yaruss, Coleman, & Quesal, 2012). As indicated by Ribbler (2006), "For students who stutter, the impact goes beyond the communication domain. In fact, stuttering can affect all areas of academic competency, including academic learning, social-emotion functioning, and independent functioning" (p. 15). Fluency disorders, however, do not necessarily affect test scores or subject grades. It is incumbent upon the SLP to inform the IEP team about the multiple ways stuttering can influence educational performance.