Behavior Assessment Battery: A Pilot Study of the Affective, Behavioral, and Cognitive Correlates Surrounding Spasmodic Dysphonia

Behavior Assessment Battery: A Pilot Study of the Affective, Behavioral, and Cognitive Correlates Surrounding Spasmodic Dysphonia *Martine Vanryckeghem, *,†Bari Hoffman Ruddy, and †Jeffrey Lehman, *yOrlando, Florida Summary: Objective/Hypothesis. This study investigates if adults with adductor spasmodic dysphonia (ADSD) report to experience anxiety and voice problems in particular situations, indicate the presence of negative speechassociated attitude, and/or the use of coping behaviors, by means of the Behavior Assessment Battery (BAB) modified for voice. Methods. Thirty-two participants with ADSD and 32 adults without a voice disorder participated in this study. Each person completed four different BAB-Voice subtests. These standardized self-report tests are adaptations of the original BAB for people who stutter and explore an individual’s speech-related belief, negative emotional reaction to and speech problems in particular speech situations, and the use of concomitant behaviors. Results. Individuals with spasmodic dysphonia (SD) scored statistically significantly higher compared to typical speakers on all BAB subtests, indicating that individuals with SD report being significantly more anxious and experiencing significantly more voice problems in particular speech circumstances. They also reported a significant amount of negative speech-associated attitude and the use of a significant number of coping behaviors. Internal reliability was good for three of the four BAB subtests. Conclusions. The BAB is capable of reflecting the dimensions that surround the disorder of SD. The self-report measures have the potential to augment the observations made by the clinician and may lead to a more diverse and allencompassing therapy for the person suffering from SD. Future research with a revised version of the BAB-Voice will continue to explore the validity, reliability, and replicability of the initial data. Key Words: Adductor spasmodic dysphonia–Voice disorder assessment–Behavior Assessment Battery.

INTRODUCTION Spasmodic dysphonia (SD) is a complex neuromotor disorder characterized by involuntary spasms of the laryngeal muscles during speaking.1 Historically, the diagnostic label of SD has varied with multiple etiologies, ranging from neurologic to psychiatric, considered as causative.1–4 Current evidence supports a neurogenic etiology and classifies SD as a taskspecific focal dystonia. Although no clear relationship exists between SD and damage to any one particular area of the brain or brain stem, recent studies have demonstrated a relationship with areas in the basal ganglia, thalamus, sensorimotor cortex, and cerebellum.5–16 Although the etiology of SD is unclear, onset typically occurs during the fourth decade of life17 and is more prevalent in women (nearly 80%) than in men.18 The National Spasmodic Dysphonia Association estimates that 50 000 people in North America are affected by SD. The disorder can present in a variety of forms (adductor, abductor, mixed, or tremor), each of which is characterized by distinct vocal symptoms. Of these, adductor SD (ADSD) is the most common form of SD and is characterized by irregular and uncontrollable tight or strained-strangled voice stoppages or Accepted for publication March 17, 2015. From the *Department of Communication Sciences and Disorders, University of Central Florida, Orlando, Florida; and the yThe Ear Nose Throat and Plastic Surgery Associates, Orlando, Florida. Address correspondence and reprint requests to Martine Vanryckeghem, Department of Communication Sciences and Disorders, University of Central Florida, 4364 Scorpius Street, HPA 2 Suite 101, Orlando, FL 32816-2215. E-mail: [email protected] Journal of Voice, Vol. -, No. -, pp. 1-8 0892-1997/$36.00 Ó 2015 The Voice Foundation http://dx.doi.org/10.1016/j.jvoice.2015.03.007

breaks, which are caused by intermittent and irregular closure (adduction) of the vocal folds during phonation.1,19 Individuals with ADSD frequently demonstrate symptoms also commonly associated with stuttering. Chief among these is ‘‘speech interruption,’’ characteristic fluency breaks due to irregular muscular spasms. As with stuttering, individuals with ADSD also demonstrate increased effort during speech tasks, particularly when attempting to push through a spasm, and laryngeal involvement is evidenced during these interruptions in the forward flow of speech.19–24 In the field of fluency disorders, more specifically stuttering, several researchers have indicated that, what encompasses a person who stutters, includes more than just a speech impediment.25–32 There is abundant evidence that, what impacts people who stutter (PWS) goes far beyond an interruption of the forward flow of speech and the dysfluencies that they exhibit. In addition to the stuttering behaviors that are obvious, PWS might use an array of behaviors that are secondary to the stuttering.25–27,33–35 These behaviors are used to cope with the fluency failures that PWS experience. In addition, most PWS think negatively about their speech and way of speaking,26,33,36–44 and many of them face anxiety and experience speech disruption that is linked to particular sounds, words, and/or speech situations.26,44–53 Self-report measures are a valuable means of investigating the affective, behavioral, cognitive, physical, and social dimensions that characterize stuttering. These self-report measures provide the clinician with a multidimensional ‘‘inside’’ view26 of the speech and speech-related difficulties experienced by an individual before and during treatment. These reflective self-report measures provide a glimpse of symptoms ‘‘through

2 the eyes of the client’’26 and complement both the qualitative and quantitative external observations made by the clinician. Self-report measures also enable the clinician to direct attention to relevant negative emotional, speech disruptive, secondary adjustive, and attitudinal elements of the presenting complaint. The Behavior Assessment Battery (BAB) is a standardized instrument that assesses the dimensions that surround stuttering.25–27 The BAB includes a series of tests that measure the affective (A), behavioral (B), and cognitive (C) facets of stuttering, considered collectively as the ‘‘ABC’’ components. The reliability and validity of the BAB and its separate subtests have been reported on in repeated cross-cultural investigations.26,32,35,45,46,49,50 One of these BAB subtests, the Speech Situation Checklist (SSC), provides a means of evaluating a client’s reported emotional reactions and dysfluency throughout a range of different speech situations; the Behavior Checklist (BCL) serves to inventory the number, type and frequency of avoidance, and escape responses secondary to the anticipation or the presence of speech difficulty; and the Communication Attitude Test for Adults (BigCAT) is a communication attitude scale assessing speechassociated beliefs. Taken together, these instruments provide the clinician with stable and true measures of phenomena that are relevant to everyday clinical practice. As has been the case within the health care field in general, the subspecialty of voice disorders has increasingly acknowledged the psychosocial effects of impairment, in this case, the impact of a voice disorder such as SD, on day-to-day life.54–61 The current approaches emphasize the meaning of an impairment or disability from the patient’s unique perspective, so that effective treatment planning and implementation of interventions have the potential to produce the greatest benefit for each individual.62 In this vein, the Voice Handicap Index (VHI),63–65 the Voice-Related Quality of Life questionnaire (V-RQOL),66–68 and the Voice Disability Coping Questionnaire69 are widely reported means of measuring the psychosocial impact of voice disorders such as SD. An additional questionnaire, the Voice Activity and Participation Profile (VAPP),59 evaluates an individual’s perception of a voice problem, activity limitation, and restrictions in participation, using the World Health Organization’s International Classification of Impairments, Disabilities, and Handicaps model.70 The psychosocial impact of SD can also be quantified through the use of more general health-related questionnaires1,64,71,72 that, although not specifically focusing on SD, measure the use of coping behaviors in social and occupational settings. Recent qualitative findings by Baylor and colleagues62 reveal that individuals with SD frequently report a dissociation between the sound of their voices and feelings, personality, or capabilities. Collectively, this work has advanced and broadened our understanding of the physical, functional, and psychosocial consequences of SD. However, much is unknown about the situational difficulties and the coping strategies used by individuals with SD. Obtaining an ‘‘inside view’’ from these patients can be challenging because of the multitude of variables which shape each individual’s experience.62 Although anecdotal reports within the scientific

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literature suggest that symptoms of SD interfere with family, social, and occupational engagement, the specific environments, the coping mechanisms, the emotional reaction, the speech-related belief system, and personal factors that shape these effects require further evaluation.62 Whereas the VHI, V-RQOL, and VAPP have shed light on the variables surrounding voice disorders in general, the aforementioned elements have not been captured previously in research that specifically focused on individuals with ADSD. The current investigation involving the BAB will allow for the assessment of the particular domains that are disorder-specific. This investigation involved a novel application of an adapted version of the BAB for PWS to adults with ADSD to determine the extent to which adults with SD score differently on the BAB subtests compared with typical speakers, and whether gender had an impact on the scores. Also, the possible relationship between the affective, behavioral, and cognitive components related to SD was examined. In addition, within- and between-group item analyses were performed to determine each test’s internal reliability and the extent to which each test item contributes to differentiating individuals with SD from typical speakers. On the basis of this analysis, certain items might, in future research, need to be eliminated from the original item pool. METHODOLOGY Participants Thirty-two adults with ADSD and 32 adults without a voice disorder, between the ages of 31 and 86 years participated in this research study. The mean age for the experimental group was 61.60 years (standard deviation, 13.30) and 58.70 years (standard deviation, 12.60) for the control group. All individuals in the experimental group were diagnosed with ADSD. The diagnosis of ADSD was made by a voice care team consisting of an otolaryngologist and a speech-language pathologist practicing in the greater Orlando area, with a >25-year history of evaluating and treating patients with SD. All SD participants were recruited from this center. The voice care team differentiated ADSD from muscle tension dysphonia by means of endoscopic, acoustic, and perceptual evaluation tools. Endoscopic criteria included the presence of two or more inappropriate adductor spasms during sustained vowel phonation and during the reading of a connected speech narrative. Criteria for the acoustic analysis included two or more phonation breaks, frequency shifts, or evidence of aperiodicity. Individuals demonstrating symptoms of concomitant vocal tremor were excluded from this study. The group of participants with SD consisted of six men and 26 women, which is representative of the gender ratio among the population of people with SD. All SD participants were either 6 months after the injection of botulinum toxin or had never received an injection, and did not receive any other form of treatment. The sample of individuals without voice disorders was recruited through businesses, professional and private clubs and organizations, religious groups, and so forth, via word of mouth. Participants in this group were more equally divided among men and women (15 and 17, respectively) to represent the general population. The sample of typical speakers was

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Behavior Assessment Battery

matched for age with the experimental group using age bands: age 31–45 years (4), age 46–60 years (13), and age 61–86 years (15). All participants had to be able to understand and read English. Individuals were excluded from the study if they reported having had in the past or currently having (other) speech and/or language disorders. Procedure and materials Individuals interested in participating in this study were given an informational sheet as well as a consent form approved by the University of Central Florida Institutional Review Board {SBE-10-07246}. Participants were told about the purpose of the investigation, and that they would be asked to fill out a series of self-report inventories. Every adult was asked to fill out four different tests that are part of the BAB-Voice.73 The BAB consists of the BigCAT, SSC-Emotional Response (SSC-ER), SSCSpeech Disruption (SSC-SD), and the BCL. These standardized self-report tests are adaptions of the original BAB for PWS26,32,74 and explore an individual’s speech-associated attitude, reactions to speech situations, and speech-related behaviors, by asking a person to circle ‘‘true or false,’’ to check or rank his or her reaction to speech situations on a five-point scale, and to indicate the coping responses, if any, that the respondent might use to cope with his or her voice problem. The participants in both groups were asked to fill out the questionnaires on an individual base in the presence of a graduate research assistant who was trained by the senior author, also test coauthor (M.V.), in the administration of the tests. The test battery’s initial content validity determination was made on the basis of logical examination of the test items’ content to see how well they sample the behavior or characteristics to be measured, if they are sampled from the domain of interest and represent the characteristics of the phenomena surrounding SD. The rationale for including certain items was made by the second author (B.H.R.), a specialist in the area of voice, together with other specialists in the field. It was based on thorough review of the literature and anecdotal reports from patients over a 15-year history of evaluating and treating individuals with ADSD. The questionnaires’ test instructions were read aloud by the administrator as the participant followed along silently. Together with the participant, the examples on the cover page of the test were filled out and discussed. If the person did not have any questions and the instructions were clear, he or she was instructed to fill out the self-report test on his or her own. If needed, the test administrator would clarify the instructions and provide an additional example. Filling out each questionnaire took approximately 10–15 minutes. The order in which the different tests were administered was randomized to guard against an order effect. Test administration took place on two different days. More than one test per day was administered if they were not two sections of the same test, as is the case with SSC-ER and SSC-SD. This was dependent on the order of the tests given to an individual. If the order was BigCAT, SSC-SD, SSC-ER, and BCL, BigCAT and SSC-SD could be administered the same day, but SSC-SD and SSC-ER were not to be filled out the same day.

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The BigCAT explores a person’s speech-associated attitude. The person is asked to indicate, by circling ‘‘true or false,’’ whether each of the 35 statements applies to him or her. If the individual is unsure about how to answer, he or she was instructed to give the response that most represents what he or she currently thinks about his or her voice and way of speaking. Answers that are indicative of a negative belief related to one’s voice, receive a score of 1. As such, the scores on this test can range from 0 to 35. A higher score indicates more negative thinking. An example of items on the BigCAT include: ‘‘there is something wrong with my voice, I am sometimes embarrassed by my voice, some sounds or words get stuck in my throat’’, and so forth. The 51-item SSC has two components, one that investigates the amount of negative emotional reaction to particular situations that involve speaking (SSC-ER), and a second section that determines the amount of reported speech disruption in the same situations described (SSC-SD). The amount of anxiety, worry, fear (ER), and the extent of speech disruption are indicated on a five-point scale from being absent (not at all) to present to a great extent (very much). The sum of all answers provides the total score on the SSC, possibly ranging from 51 to 255. Examples of SSC items are: ‘‘talking on the phone, talking to a stranger, saying a sound or word that previously had been troublesome’’, and so forth. Finally, the BCL provides an inventory of those behaviors that are reportedly being used as devices to cope with the anticipated or experienced voice problem. After reading the instructions on the cover page that only involve column I of the self-report test, the person checks off those behaviors that are presently being used as coping behaviors. On completion of column I, the respondent indicates, in column II, the frequency with which he or she uses the particular behaviors that have been checked off. Given that 95 behaviors are being listed, the score on this test can range from 0 to 95. Examples of items on the BCL include: ‘‘avoiding eye contact, taking a deep breath before speaking, clearing your throat, and substituting one word for another’’, among others. Statistical analyses Statistical analyses will be performed that relate to the total scores on the different BAB tests and to the item scores per test. Total score analyses will include a comparison between the two groups of participants by means of t tests (preset a level of .05) and the calculation of effect size. Potential gender differences in the test scores will be explored via t tests. In addition, correlational data between the BAB subtests will be obtained for each group separately. Item analyses will allow determination of the BAB tests’ internal reliability by means of Cronbach a and item-total score correlations. For each test, a betweengroup item difference will be established by means of t tests. RESULTS Total score analysis Normative and comparative data. Table 1 presents that adults with SD scored, on average, 142.17 (standard deviation,

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TABLE 1. Measures of Central Tendency and Variation for Adults With and Without SD (SD and Control) for SSC-ER, SSC-SD, BCL, and BigCAT SSC-ER

Mean Standard deviation Med Min Max

SSC-SD

BCL

BigCAT

SD

Control

SD

Control

SD

Control

SD

Control

142.17 53.15

69.18 22.74

148.41 57.81

63.66 15.31

14.79 11.13

5.13 7.38

27.33 8.77

3.53 4.17

152.00 51 225

63.00 51 134

148.5 54 245

58.00 51 114

12.00 2 51

2.00 0 26

31.00 3 35

2.00 0 15

53.15) on the SSC-ER. This is in sharp contrast with the typical speakers who had a mean score of 69.18 (standard deviation, 22.74). The SSC-ER score of people with SD falls more than three standard deviations above the score of the control group. Whereas for both groups of participants, the minimal score was 51, the maximum score for the experimental group was far beyond that of the control group. T tests indicated that the average scores on the SSC-ER for both groups differed significantly (t ¼ 6.964, P ¼ 0.000) and the effect size of d ¼ 1.817 (95% CI, 1.2292–2.4041) can be said to be large. The same phenomenon is observed relative to the SSC-SD. As can be seen in Table 1, the maximum score of 245 for the group of individuals with SD is more than double that of the control group (114). The average score of 148.41 (standard deviation, 57.81) for the SD group is situated five standard deviations above the mean score (63.66) of the control group (standard deviation, 15.31). As anticipated, a t test revealed that both groups score statistically significantly different (t ¼ 8.017; P ¼ 0.000). Also, for this section of the SSC, the observed effect size was large: d ¼ 2.004 (95% CI, 1.4036–2.6047). The BigCAT’s range of scores for both groups is disparate. The mean scores of 27.33 (standard deviation, 8.77) for the experimental group and 3.53 (standard deviation, 4.17) for the control group are distinctly different. Specifically, adults with SD score six standard deviations above the average typical speaker. Clearly, the means differ to a statistically significant extent (t ¼ 14.537; P ¼ 0.000). The effect size of d ¼ 3.4016 (95% CI, 2.6575–4.1456) reflects average scores representing two distinct populations. As was the case with the other BAB subtests, the BCL scores for typical speakers span a shorter range compared to people with SD. The average BCL score of 14.79 (standard deviation, 11.13) for individuals with SD is clearly elevated above that of the sample of typical speakers (mean, 5.13; standard deviation, 7.38). A t test (t ¼ 3.821) revealed that this difference in scores is statistically significant (P ¼ 0.000). This time, the effect size was d ¼ 1.047 (95% CI, 0.4748–1.6187). Correlations. A point worth exploring was whether or not the scores on the different BAB tests correlated significantly for both samples. As presented in Table 2, the anticipated relationship between the two sections of the SSC, an indication of emotional reaction and speech disruption relative to particular situations, was confirmed by a high and significant correlation

for people with SD (0.82; P ¼ 0.01). In addition, the average score for both sections of this test did not differ significantly (t ¼ 0.616; P ¼ 0.544). Both the SSC-ER and SSC-SD correlated moderately high with the BigCAT (0.64 and 0.69; P ¼ 0.01, respectively). However, as can be seen in Table 2, none of the tests correlated significantly with the BCL. For the sample of typical speakers, the highest correlation of 0.73 (P ¼ 0.01) was found between the two parts of the SSC. Also for this group, the average scores on the two SSC sections did not differ significantly (t ¼ 1.543; P ¼ 0.133). Moderate and significant (P ¼ 0.01) correlations were observed between the SSC sections and the BigCAT. The lowest correlations were those with the BCL subtest. Nevertheless, they were all significant at the 0.01 (r ¼ 0.50) or 0.05 level. Gender. For both groups, it was investigated whether gender had a significant impact on the BAB scores. Table 3 indicates that, for the sample of individuals with SD, except for the BigCAT where the scores were essentially equal, the women scored descriptively higher on the BAB tests compared to the men. This difference was not statistically significant, except for SSC-ER (t ¼ 2.654; P ¼ 0.013). For the sample of typical speakers, this phenomenon of higher scores among the women was not observed. As a matter of fact, on three of the four subtests, the men scored descriptively somewhat higher compared to the women. However, none of the average scores differed significantly between men and women. Item analyses Within-group analysis. As indicated in Table 4, Cronbach a values for the experimental and control group are very TABLE 2. Pearson Product Moment Correlations Between SSC-ER, SSC-SD, BigCAT, and BCL for the Sample of SD and Control Participants SD Participants Test SSC-ER SSC-SD BigCAT

Control Participants

SSC-SD BigCAT BCL SSC-SD BigCAT BCL 0.82

0.64 0.69

0.19 0.05 0.19

0.73

0.66 0.54

0.50 0.42 0.37

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TABLE 3. Means and Standard Deviations by Gender for SSC-ER, SSC-SD, BigCAT, and BCL SSC-ER

Participants with SD Mean Standard deviation Typical Speakers Mean Standard deviation

SSC-SD

Female

Male

Female

Male

Female

Male

Female

99.57 48.83

156.05 49.10

135.75 53.59

152.63 59.64

27.25 8.62

27.33 9.14

9.33 7.89

16.61 11.63

72.63 26.13

65.94 19.27

62.19 16.91

65.13 13.92

3.93 4.27

3.18 4.19

5.87 7.68

4.40 7.26

Between-group analysis. For each BAB subtest, item comparisons were made between the experimental and control group through t tests, with a preset alpha value of 0.05. For SSC-ER, 49 of 51 items, and for SSC-SD, 50 items differentiated the two groups to a statistically significant extent. In both tests, item 10 (arguing with parents) did not differentiate the two groups, with the addition of item 25 (talking after having had a few alcoholic drinks) for SSC-ER. Thirty-four of the 35 BigCAT items differentiated the two groups to a statistically significant extent. Item 6 (I have less trouble with my voice when I talk to very young children) did not discriminate the two groups. The BCL was the only test where few items, 14 of the 95, significantly differentiated the experimental from the control group. DISCUSSION From the data described above, it is obvious that adults with ADSD score statistically significantly higher compared to typical speakers on all BAB subtests. Specifically, individuals with SD TABLE 4. Cronbach Alpha Correlations for SSC-ER, SSC-SD, BigCAT, and BCL, for Experimental and Control Groups

SSC-ER SSC-SD BigCAT BCL

BCL

Male

high, with the highest value being .99 (SSC-SD for the experimental group) and the lowest .87 (BCL for the experimental group), pointing to a very favorable internal reliability for the different tests. A bivariate analysis was performed to derive the significance value for each individual item as it relates to the total score for each of the BAB tests. For the experimental group, all of the 51 items on SSC-ER and SSC-SD and 33 of the 35 BigCAT items correlated significantly with the total score. However, only 61 of the 95 BCL items correlated significantly with the total score. For the control group, 46 SSC-ER items, 40 SSC-SD items, 32 items from the BigCAT, and 79 items from the BCL correlated significantly with the total score.

Test

BigCAT

Experimental Group

Control Group

.99 .99 .95 .87

.97 .96 .92 .94

report being significantly more anxious of speaking in particular situations and experiencing significantly more voice problems in those circumstances. As seen, the average SSC-ER and SSC-SD scores of people with SD were situated more than three and five standard deviations, respectively, above the mean of those without a voice problem. This observation, together with the fact that both sections of the SSC correlate highly and their means do not differ significantly, underscores that voice problems, specifically ADSD, are tied to negative emotional reaction elicited during particular speaking situations. The speech problem that individuals with SD face is linked to negative experiences that they have had in particular speech situations. These findings are similar to those observed in studies comparing PWS to people who do not stutter (PWNS). In a Belgian research study,26 PWS scored 126.88 (standard deviation, 40.22) on SSC-ER compared with 82.54 (standard deviation, 22.02) for PWNS. In a similar United States-based research investigation,75 PWS had an average score of 147.06 (standard deviation, 36.18) compared to 69.71 (standard deviation, 15.91) for PWNS. In both cases, the difference in mean scores between the two groups was statistically significant. The same holds for the data that relate to the SSC-SD. In the study by Brutten and Vanryckeghem,26 PWS scored statistically significantly higher (mean, 130.10; standard deviation, 35.44) compared to PWNS (mean, 73.71; standard deviation, 21.26). This difference in scores was confirmed in the study by Vanryckeghem and Reifschneider,75 where an SSC-SD mean score of 144.30 (standard deviation, 35.55) was obtained for PWS and 63.66 (standard deviation, 14.12) for PWNS. The current data obtained from individuals with ADSD and a cohort of typical speakers reveal similar effects. As has been observed in PWS, the data that stem from the SSC point to the fact that adults with SD clearly report that certain speech situations, such as talking on the telephone, engaging in social situations, and talking in loud environments, evoke negative emotional reaction and speech disruption. This would confirm what Cannito et al1 describe as communication apprehension. Here, as reported by Baylor et al,62 individuals with SD perceive their voices as not dependable and, therefore, avoid social situations or speaking in general, out of fear of embarrassment and an inability to predict voice quality. Results obtained through administration of the BigCAT indicate that individuals with ADSD think negatively about

6 their speech. This finding mirrors what is known about PWS. In an investigation by Vanryckeghem and Brutten,74 the mean BigCAT score of PWS (26.97; standard deviation, 4.97) differed significantly from that of PWNS (4.43; standard deviation, 3.50). This presence of negative speech-associated attitude, has been well documented among adults who stutter32,36–38,44 and can now also be confirmed among individuals with ADSD. Past research investigating the consequences of SD on communication-related quality of life and self-perception have indicated that the presence of ADSD is related to feelings of frustration, embarrassment, self-consciousness, and incompetence.62 Negative thoughts as it relates to speech performance may cause individuals with ADSD to avoid certain work environments, potentially limiting employment opportunities, job advancement or, for some, necessitating a complete career change caused by fear for their employability in the face of a chronic voice disorder. The current data obtained through the BigCAT confirm the negative impact of ADSD on a person’s thinking about his or her speech and the malattitude it creates. These results are unique in that they relate the existence of negative thoughts about communication to the specific quality of life domains, which were otherwise not identified. Individuals with ADSD report to use a significant amount of coping behaviors to avoid or escape the physical manifestations of the disorder. Participants with ADSD, on average, use 15 distinct coping behaviors. In comparison, PWS reported using 21 coping behaviors (standard deviation, 11.39) in a Belgian investigation with the BCL35 and 19 (standard deviation, 9.84) in a United States-based research study.76 The similarity between adults with SD and PWS is evident. Both groups indicate using a wide range of coping behaviors to deal with the various physical and functional manifestations of their disorder. Common coping strategies used by individuals with ADSD include planning ahead, avoiding difficult situations, and avoiding talking all together.62 Epstein et al69 also found that individuals with SD demonstrated avoidance and passive coping strategies (ie, relinquishing control of a situation) significantly more than individuals with muscle tension dysphonia and other voice-related disorders. Gender effects were not observed for the SSC-SD, BigCAT, and BCL scores of individuals with ADSD, although apparent trends were present, with women, as a group, tending to score higher than the men on the SSC-SD and BCL. Statistically significantly higher scores for women compared to men were seen only for SSC-ER. This investigation was limited through enrollment of fewer men than women with ADSD. Future investigations with greater numbers of male participants will be able to better elucidate what, if any, gender disparity exists. There is reason to believe that gender may exert an influence on the measures of interest as a significantly higher SSC-ER score for female compared to male PWS was found during a Belgian investigation.26 In the same study, the SSC-SD score for female PWS was higher than that of the male PWS but not significantly so. For the other BAB subtests, the BCL and BigCAT, average scores of female compared with male PWS were also descriptively, but not significantly, higher.26,32,74

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The item analyses data point to a solid internal reliability of the different BAB subtests. As it relates to the SSC-ER and SSC-SD, all items correlated significantly with the total score for the experimental group. When comparing the item means for both groups, only item 10 (arguing with parents) did not differentiate the two groups. If this result is being replicated, a decision might be made to eliminate this item from the test. For the BigCAT, it were only items 6 (I have less trouble with my voice when I talk to very young children) and 12 (some people find my voice strange) that did not correlate significantly with the total score, and only item 6 did not differentiate the groups to a statistically significant extent. The same ruling relative to item removal might be made after replication research. The BCL seemed to be the subtest that was weaker, compared to the other three tests, as far as internal consistency is concerned, and its discriminative power in separating the two groups. Given this information, and the fact that this test is quite extensive with its 95 items, deletion of several BCL items might need to take place. CONCLUSIONS The data from the current investigation are novel and interesting. Undoubtedly, the standardized tests that are part of the BAB are capable of reflecting the dimensions that surround the disorder of ADSD. The BAB subtests provide the clinician, in a nonconfounding way, with information about the affective, behavioral, and cognitive dimensions that surround ADSD. Although the data show that the tests are interrelated, they investigate different dimensions. The standardized BAB tests allow for quantification of speech-related anxieties and negative speech-associated attitude. Additionally, the BAB reveals problematic speech situations and catalogues coping behaviors that are used in response to a voice problem. These self-report measures augment the observations made by the clinician and assist in diagnostic decision-making specific to ADSD. A more fully rounded assessment like this also allows for a multimodal treatment plan, which, if warranted, can better address the array of physical, functional, and psychosocial components of ADSD.77 In any case, the additional dimensions obtained through the client, via standardized self-report, can lead to a more diverse and all-encompassing therapy for the person suffering from SD. FUTURE DIRECTIONS AND LIMITATIONS The obtained internal reliability pilot data, described in this study, will allow for some test adaptations. A follow-up investigation using a United States’ representative sample of adults with and without ADSD, using a revised version of the SSC, BigCAT, and BCL, will shed light on the replicability of the BAB scores and the usefulness of the test battery in the assessment of individuals with ADSD. Future research will address some of the limitations of the present pilot study and explore more fully the psychometric parameters of the BAB, including internal and test-retest reliability and validity determination. The fact that the sample in the present study had a preponderance of female over male participants in the

Martine Vanryckeghem, et al

Behavior Assessment Battery

experimental group, and an essentially equal split in the control group can be seen as a limitation. The rationale for a more equal split among the typical speakers was chosen to represent the population at large. Also, in previous studies with PWS and PWNS, the women typically did not score significantly different compared to the men, except in one study as it related to SSCER. However, in a follow-up investigation with a more representative sample across the United States, steps will be taken to match the participants for gender and age. Furthermore, in future studies with the revised BAB, construct validity will be further investigated through factor and discriminant analysis. The present pilot study was aimed at testing the feasibility of the BAB tests for individuals with SD. Through this research, we were able to establish the strength of this diagnostic tool and make necessary adjustments. At this point, the known-groups technique—where the test instrument was administered to two groups expected to differ in their scores—has clearly shown that both groups differed to a statistically significant extent, which attests to the test battery’s construct validity and the fact that the test profile is similar to that of PWS. Relative to criterion-related validity, the empirical examination of how well the BAB subtests correlate with some outside validating criterion, poses a challenge as far as the selection of an appropriate outside validating criterion is concerned. Given that there is no standardized test available that, in a singularly, nonconfounding way, investigates communication attitude, anxiety and voice problems in particular situations, or the use of coping strategies, the determination of criterion-related validity was not made at this time. We did however determine the relationship between the different BAB tests. It is our intention to administer scales such as the VHI, V-RQOL, and VAPP concurrently with the BAB in a future nationally based research. Acknowledgments The authors wish to acknowledge the individuals who participated in this study. In addition, the authors thank the graduate assistants and undergraduate students in the LEAD Scholars program at the University of Central Florida who took part in this investigation. REFERENCES 1. Cannito M, Murry T, Woodson G. Attitudes toward communication in adductor spasmodic dysphonia before and after botulinum toxin injection. J Med Speech Lang Pathol. 1994;2:125–133. 2. Arnold GE. Spastic dysphonia: I. Changing interpretations of a persistent affliction. Logos. 1959;2:3–14. 3. Brodnitz FS. Spastic dysphonia. Ann Otol Rhinol Laryngol. 1976;85(2 pt. 1):210–214. 4. Heaver L. Spastic dysphonia: II. Psychiatric considerations. Logos. 1959;2: 24. 5. Hartman DE, Aronson AE. Psychogenic aphonia masking mutational falsetto. Arch Otolaryngol. 1983;109:415–416. 6. Blitzer A, Brin MF, Fahn S, Lovelace RE. Localized injections of botulinum toxin for the treatment of focal laryngeal dystonia (spastic dysphonia). Laryngoscope. 1988;98:193–197.

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