Physician's screening procedure for children who may stutter

J. FLUENCY DISORD. 14 (1989), 57-66

PHYSICIAN’S SCREENING PROCEDURE FOR CJJILDREN WHO MAY STUTTER GLYNDON California

JEANNA Rileys

D. RILEY

State

Speech

University,

Fullerton

RILEY and Language

Institute,

Tustin,

California

The purpose of this study was to devise a screening protocol that was data based and consistent with commonly accepted caseload selection criteria. Eighty children who were accepted for treatment were compared with 31 children who were monitored for 2 years and who did not need treatment. Disfluency types, frequency of abnormal disfluencies, reactions of child and listeners, and reported number of months since onset are suggested for use by the physician as referral criteria.

A number of researchers in recent years have provided support for beginning the management of children’s disfluencies as soon as they become clearly abnormal (Costello, 1983; Curlee and Perkins, 1984; Riley and Riley, 1983, 1984; Shine, 1980; Starkweather, 1980). These investigators reported that the kind of attention involved in direct management of stuttering does not cause it to become worse. If all very young children who experience clearly abnormal disfluencies could be enrolled in appropriate treatment as soon as their stuttering was diagnosed, probably only about 20% of them would be likely to continue to stutter during the school years and later in life. Prognosis for a cure is much better with children under 8 years of age; from 8 to 11 years the prognosis is less favorable but still better than when treatment is started at age 12 or older (Riley and Riley, 1984; Starkweather, 1980). Also, by enrolling the preschool child in therapy, we reduce the chances of socially punishing experiences in the child’s life. Cooper and Cooper (1985) reported that speech pathologists’ attitudes about early intervention changed between 1973 and 1983. There was a meaningful increase in the percentage of clinicians willing to enroll kindergarten or first grade children in therapy for stuttering (from 42% in Address correspondence stitute, 17400 Irvine Blvd.,

to Glyndon and Jeanna Riley, Suite K, Tustin, CA 92680.

0 1989 by Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas. New York, NY 10010

Rileys

Speech

and Language

In-

57 0094-730X/891$3.50

58

G. D. RILEY

and J. RILEY

1973 to 53% in 1983). Also, the 1983 sample was more willing to use the word stuttering or stutterers than the 1973 sample. Some children will outgrow their stuttering within 2 or 3 years of onset without professional management. Ingham (1984) reviewed the literature on stuttering chronicity and concluded, “approximately 40% to 50% of children described as stutterers will recover by 6-9 years of age” (p. 72). In our experience with children who were referred for a speech/language evaluation because of their disfluencies, 28% were not enrolled in treatment. This lower percentage is probably due to the fact that parents become concerned about their children’s disfluencies because they are getting more severe, so children with mild disfluencies were probably not referred. Any problem that is likely to persist for 3 years would seem to warrant consideration for therapy. Most physicians are unaware of the trend to treat stuttering at an earlier age, and they do not have criteria for making the referral. One of the purposes of this study was to develop a useful procedure that will encourage medical doctors and other professionals to refer children to a speech pathologist at a younger age. The other purpose was to suggest some criteria for making the referral.

PROCEDURES By 1977 researchers in several different laboratories had developed similar criteria for enrolling a disfluent child in therapy. The selection of areas for this investigation were based on the findings of Stromstra (1965), Van Riper (1971), Cooper (1973), and Adams (1977). Stromstra made spectographic recordings of 38 children who were thought by their parents to stutter. About 10 years later he reevaluated these same children. Twentyseven children (71%) still stuttered, and 11 (29%) did not. Of the 27 children who still stuttered, 24 had air-flow breaks and abnormal transitions during their stuttering moments. Only one of the 11 who had outgrown the stuttering had these abnormalities. Using Stromstra’s data, other research, and clinical observations, Van Riper made a comprehensive chart of symptoms that characterize the children who will and will not outgrow their stuttering. The spectographic abnormalities often show up in tense. silent prolongations (phonatory arrests and articulatory postures), tense prolongations of vowels, consonants or nonspeech sounds, and tense partword repetitions. Van Riper’s other symptoms of chronicity included reactions to stress and evidence of awareness. Cooper used Van Riper’s list and several historical indicators to construct his Stuttering Chronicity Prediction Checklist. Adams developed five criteria to differentiate “incipient” stuttering from “normal nonfluency.” They were: 1) at least 10 disfluencies per 100 words; 2) Part-word repetitions, audible-silent prolongations, and broken

PHYSICIAN

SCREENING

PROCEDURE

59

words predominate; 3) at least three unit repetitions per part-word repetition (i.e., b-b-b-ball); 4) the schwa will be perceived; and 5) frequent difficulty in starting and/or sustaining voicing or air flow for speech. In 1977 we organized the published criteria into a test procedure which eventually became the Stuttering Prediction Instrument (Riley, 1981). It has been used since then as part of a caseload selection procedure and its items were used in this present study. In 1981 we analyzed the treatment selection criteria using 85 children who were accepted for therapy and 17 who were not. Table 1 (Table VI from the SPI) shows the results of that analysis. Note that all of the variables except Age, Sex, and Family history of stuttering were significant beyond p = 0.01. This present study reorganized the variables from the 1981 study and defined them in lay terms. We included length of time since onset as an additional variable.

Subjects and Instruments Of the 111 children (ages 4-7 years) who were the subjects for this study, 80 were accepted for therapy, and 31 were monitored but received no therapy. None of the monitored children needed therapy within 2 years. The children were seen at a university speech/language clinic, a private practice, and four public school districts. Each child was tape-recorded 1) during conversation with an experienced clinician without the parent(s) present, and 2) while conversing with one parent. The parents were interviewed to determine age of onset and any accompanying conditions and to ask if they considered the speech samples we had recorded to be typical of the child’s stuttering. The child was scheduled for additional appointments until the clinician had heard disfluencies that the parents judged as “about average” or “worse than average.” The clinicians made notes about the visible symptoms such as silent prolongations and physical concomitants. The data were derived from the tape recordings, notes made during taping, and notes made during the parent interview for the Stuttering Prediction Instrument (SPI), and a Stuttering Severity Instrument (SSI) (Riley, 1972).

Data Analysis Using the data from the SPI and the SSI, we computed the percentage of false positives for each symptom and the percentage of children who presented with each symptom. The results of those computations are shown in Table 2. The items with the lowest false positive values are the most powerful predictors of need for therapy but not all children have these symptoms.

Instrurnent,for

22.2

IO-37

SPI Total Predicrion

1.2 1.7 .4 I.3 0.3 0.3 1.4 5.4 2.3 2.5 I.8 2.8 3.2 6.5

O-IO o-2 o-2 o-2 o-2 o-2 o-2 O-12 o-3 o-4 O-6 o-12 O-12 2-9

G. Slurtering

1.2

l-2

from: Riley

5.8

3.0-8.9

Age Sex I. Male 2. Female Fam. history Parent reac. Teased Child’s reac. Word avoid. Situation avoid. Physical con. Total reac. PWR-number PWR-severity Vowel prolong. Phon. arrest At-tic. posturing Frequency

Table reproduced

Mean

Range

Chronic stutterers

0.4 I.1 0.1 0.1 0 0.1 0.1 1.4 1.4 0.2 0.5 0 0 2.8 6.2

o-3 o-2 O-l O-l 0 O-I O-l O-5 o-3 o-1 o-2 0 0 o-7 l-13

2.1 0.5 0.7 0.7 0.7 0.6 0.8 2.3 I.0 1.3 1.9 4.3 4.6 1.9 7.0

TX: Pro Ed. 19x1

1.3

1-2

0.4

Austm,

5.7

3.1-7.6

I.6

Yourn,r+~ Children.

Mean

Range

Nonchronic stutterers

Two-tail probability 0.86 0.15 0.12 0.01 0.001 0.001 0.001 0.02 0.001 0.001 0.01 0.001 0.001 0.001 0.001 0.001 0.001

t Value 0.18 1.49 2.59 3.09 3.39 12.81 4.26 2.57 13.45 IO.28 3.52 13.98 4.39 5.92 6.51 7.60 14.92

Sd 1.3 0.5 I.0 0.7 0.2 0.2 0 0.2 0.2 1.2 1.0 0.4 0.9 0 0 1.8 3.1

Stutterers on Each Item of the SPl

Sd

of Chronic Stutterers and Nonchronic

Variable

Table 1. Probability Comparisons

PHYSICIAN

SCREENING

61

PROCEDURE

Table 2. Comparison of Symptoms Exhibited by 80 Children Speech Therapy and 31 Children Not Admitted

Admitted

to Percent false positive

Treat

Not treat

Percent with symptom

1. Part-word repetitions

Yes

No

61

6.3

2.

Yes

No

70

8.1

Yes Yes Yes Yes

No

11.0 0.0

3 or more Yes Yes Yes Yes Yes

o-2 No No No No No

46 37 50 47 66 29 78 (29% mild) 46 63 88

8-33 19.2 6.2

O-16 8.4 2.3

Variable

3. 4. 5. 6. I. 8. 9. 10. 11. 12.

of 4 or more Tension during part-word repetitions Vowels prolonged 1.5 set Phonatory arrests Articulatory postures Frequency 10% or more Physical concomitants (SSI) Word avoidance Communication frustration History of being teased Onset more than 12 months ago Stuttering severity Instrument = 13 or more Range Mean Standard deviation

No

No No

0.9 0.9 1.8 1.8 3.6 5.4 12.6 4.5

They are: phonatory arrests (4), articulatory postures (5), frequency of 10% or more (6), physical concomitants (7), and word avoidance (8). The next most powerful predictors are: SSI total score of 13 or higher (12), communication frustration (9), history of being teased (lo), part-word repetitions of four or more (l), and tension during the part-word repetitions (2). Two symptoms produced more than 10% false positives: vowels prolonged 1.5 seconds (11) and onset more than 12 months ago (12). The symptoms that could be defined in lay terms were laid out on a chart that has the most serious symptoms on the right and the normal or near normal symptoms on the left (see Appendix). This chart is the core of the physicians’ screening procedure. Background information and selected references accompany the chart. The symptoms were divided into six areas and are listed from left (normal) to right (very abnormal).

Types of Disfluencies 1. 2. 3. 4.

Repeats phrases or whole words. Interjects “uh” while thinking. Repeats the first sound of a word two or three times without tension. Repeats sound four or more times before getting the word out.

62

G. D. RILEY and .I. RILEY

5. Child has tense voice during the repetitions. 6. Child has “hard” blocks. Gets stuck on words.

Other Behaviors During Abnormal Disfluencies I. Tries to change words for fear of stuttering. 2. Child struggles to get word out as seen in facial hand, arm, or foot movements.

grimaces

and/or

Frequency of Abnormal Disfluencies (Types 4, 5, and 6) 1. Infrequent (less than 2%). 2. Frequent (one every 2-3 sentences). 3. Very frequent (one or more per sentence).

Child’s Reactions to the Abnormal Disfluencies 1. None. Seems unaware of them. 2. Child just keeps on trying. 3. Child gives up trying to say the sentence right?”

or asks “Why

can’t I talk

Other People’s Reactions to the Abnormal Disfluencies 1. No one is bothered by the disfluencies. 2. Parents are afraid he/she will not outgrow the stuttering. 3. Child is very upset by teasing or other listener reactions.

How Long Since the Abnormal Disfluencies Were First Noticed? 1. They began 2. They began 3. They began

less than 4 months ago. 4-12 months ago. more than 12 months ago.

Referring to the chart in the Appendix, one can see that there are six symptoms that are “normal” or “borderline,” five that are “abnormal,” The seven very abnormal symptoms and eight that are “very abnormal.” that were included in the Stuttering Prediction Instrument study in 1981 were all significant beyond p = 0.001. In the current study, they averaged 2.8% false positives and 57.5% of occurrence. Only two of the five “abnormal” symptoms were separate variables in the 1981 study; both were significant at p = 0.01. The average false positives was 9.5%, and occurrence was 6270. The decision to refer is based on the number of “abnormal” and “very

PHYSICIAN

SCREENING

PROCEDURE

abnormal” symptoms. The more of these symptoms that are reported for a given child, the more important it is that the child be seen by a speech pathologist. We suggest that the physician refer if there are three symptoms circled on the right-hand half of the page. Use of three symptoms as the referral criteria seemed to us to be justified by the data. Even though the false positives were quite low (ranging from 0.9 to 12.6%), the occurrence averaged only 59%. The hypothetical “average” child was likely to have about seven of the 13 symptoms, and the child with three symptoms would seem to be at risk. It is possible to select combinations of three symptoms that can occur in relatively mild cases. We believe that failure to refer a child who needs therapy has more serious consequences than referring a child who, upon examination, does not need therapy. In any event, the physician is free to use his/her clincial judgment, and the parents will have some idea of how serious their child’s symptoms are (to the extent that the chart is realistic).

DISCUSSION We hope that this screening procedure will be useful to physicians and other professionals. Perhaps further research will be encouraged in this very complex area of deciding which disfluent children need the services of a speech pathologist. We think that the chart has a reasonable data base and that the variables are probably realistic as far as they go. The decision to use any three “abnormal” or “very abnormal” symptoms as the basis for referral is open to question. With experience, it may be necessary to give the more serious items more weight. The overriding consideration was to keep the procedure simple enough to be useful without added pages of instructions. To that end, we tried to make the items self-explanatory. It remains to be seen if doctors and parents can recognize the symptoms from the labels supplied on the form. Another potential problem is that the form may not be widely distributed. We speech pathologists try to solve our problems by talking to ourselves and each other, but each of us also knows some physicians who are interested in better criteria for referring stuttering children. In an effort to encourage better distribution, the Appendix of this study is available free to anyone who is interested in giving it to perspective users. We will, of course, be interested in receiving feedback on its strengths and weaknesses. We wish to thank Rich Abrassart. director of Clinical Services at California State University, Fullerton and also the clinicians at Rileys Speech and Language Institute and the more than 20 other speech pathologists who helped gather data and monitor children for this study.

Of

Mes

Examineh

were

Comments:

AREA F How Mng since the abnormal dMuenc,es firs+ noticed)

AREA E Olhe, pxxwfe’s n?ac+io”s Lo the abmxma, disfluencxes

Child’s ,eac+u,ns +o the abnormal disfluencies

AREA D

NORMAL

WHO

SCREENING Birth

Name

sound IOU,

Date

1. They began less Lhan tow mOn+hs aga

3. They began mare fha” 12 monlhs ape

3. Child is very upset by teasing (K Orher liS,whw ,*ac+,ons

symptoms?_UooitorJ Examiner

1 or2

3 or mwe symptoms? ___JRefer)

Note the number of “Abnormal” and “Very abnormal” symptoms on the rightband half ot the page

2 Theybepan4tolZ nwnlhs ago

2. P&vents we a+,ahd ha/she WI,, no+ outgrow the st”++e,mg

I talkri@V

I Noone,s bothered by +he disN,,enc;es

2. Chdd s+,“gg,es to gef wxd out as See” I” kcral grimaces amV0, hand. *,m 0, foot mwemen+*

1. Tries to change nerds hn fea, of st”+te,r”p

3. Chrld g#ves up +fying lo say the se”+e,,cw 0, asks, “Why can’+

6 Chdd hns “ha,8 b+ccks Gets s+“ck on words

Age----

5 Chi+d has tense voice during the repetitions

VERYABNORMAL

Exam

File

2. Chdd /us+ keeps on +rymg

o, more bmes before gefbng +he word o”t

4. Repeats

ABNORMAL

Date of

ChMs

I None. Seems ““*Ware of them.

I ,n,,equen+ Uess +han 2%).

3. Repeats fhe b,s+ so”“d of a w,d 2 or 3 +imes W,+nO”+ +*ns,on

BORDERLINE

STUTTER

3. very Irequenf (one OI Inore per *en+*“ce,

MAY

PROCEDURE

2. Frequenl Klne I” every 2-3 sentences,.

I Repeats phrases 0, whole words 2 I”+er,elec+s ““h” wwe +hnb”g

CHILDREN

AREA C FIequency Of ab”o,,,,a, disffuenc:es lvPeS 4. 5. 6 61

AREA B Other behawors during ab”O,,“al diskenc,es

A

AREA

FOR

PHYSICIAN’S

APPENDIX

65

SAMPLE

LETTER TO ACCOMPANY

SCREENING

FORM

Dear Dr. Your decision regarding referral of some disfluent children on your caseload can be very important. Please look over the chart for parents and the Background Information. Note that speech pathologists with expertise in treating fluency disorders (stuttering, stammering, etc.) can help very young children who have clearly abnormal disfluency behaviors and attitudes. The parents should be asked to report on the most recent serious episode of "stuttering" and fill out the chart with these behaviors in mind. In many cases the medical doctor or other professional does not observe any stuttering in the office because: (1) Children are more disfluent when they are speaking in an excited manner and when they visit the doctor, they may feel constrained and on their best behavior. (2) Stuttering is episodic and you are likely to see the child between serious episodes. Therefore, we need to rely on the parent's report of behaviors. The chart is organized so that the more serious symptoms are on the right-hand half of the page. If there are three or more of these symptoms, we recommend referral to a qualified speech pathologist who has expertise in treating children with fluency disorders. She/he may very well decide to monitor the child for a few months and provide counseling to help prevent the recurrence of serious episodes. Please remember SERIOUS EPISODE

to have the parent in mind.

respond with the MOST RECENT

Thank you for your help in providing appropriate services to these young disfluent children. Working together we can prevent or remediate most stuttering before it threatens social, educational, and employment potentials. Sincerely,

_____I~____________~~~_~~~__~

Speech

Pathologist

66

G. D. RILEY

and J. RILEY

REFERENCES Adams. M. A clinical strategy for differentiating the normally nonfluent child from the incipient stutterer. Jorrt~rrl oj’F/uenc_v Disorders, 1977, 2. 141-148. Cooper. E. The development of a stuttering chronicity checklist for school age stutterer: A research inventory for clinicians. Jorrrnnl ofSpeech (2nd Hcrrring Disorders. 1973, 38, 215-223. Cooper. E.. and Cooper, C. Clinician attitudes toward stuttering: a decade change (1973-1983). Journcd c$‘Fl~renc~y Disorders. 1985, IO, 19-33.

of

Costello, J. Current behavioral treatments for children. In: Treatment oj’.Stutruing in Early Childhood: Methods and Issrws, D. Prins and R. Ingham feds.). San Diego: College-Hill Press, 1983. Curlee. R.. and Perkins, W. Nature and Trwtmrnt San Diego: College-Hill Press, 1984.

ofStuttering:

Nevtj Directions.

Ingham, R. Stuttering rend B~~h~~~~ior Theruppv: Clrrrent Sttrtrrs and Eqx~rirnental Foundr1tion.s. San Diego: College-Hill Press. 1984. Riley, G. Stuttering ProEd, 1981. Riley.

G. A stuttering artd Hearing

Spred7

Prediction

Instrument

.fbr Young

severity instrument for children Disorders, 1972, 37. 3 14-22.

Riley, G., and Riley, J. A component model In: Contemyorury Approuches in Stuttering Little Brown and Co., 1984.

Childrell.

Austin,

and adults.

TX:

Jownrrl

of

for treating stuttering in children. Therapy, N. Peins, (ed.). Boston:

Riley, G., and Riley, J. Evaluation as a basis for intervention. In: Trecltrnent fiw Stuttering in Early Childhood: Methods and Issues. D. Prins and R. Ingham. R (eds.). San Diego: College-Hill Press, 1983. Shine, R. Direct management of the begikrning Lungurge und Hearing, 1980. 1, 339-350. Starkweather, C. A multiprocess behavioral inars in Spewh. Lungotlgc crnd Herlring,

stutterer.

Semimxs

approach to stuttering 1980. I, 327-338.

in Sp~ecl7, therapy.

Sem-

Stromstra, C. A spectrographic study of dysfluencies labeled stuttering by parents. De Therapia Vocis et Logwlae. I. Societatis lnternationalis Logopaediae et Phonatriae, XII1 Congress Vindobonae. 1965. Van Riper, 1971.

C. The Natrut,

of Stuttering.

Englewood

Cliffs,

NJ: Prentice-Hall,