Human Voice: It's Beautiful

I can play an electric piano with the setting on choir and hear the digital sound of synthesized voices. It’s a pretty fun way to liven up tedious practice exercises. But it’s not nearly as beautiful as the sound of a real human voice.  The real human voice depends upon airflow instead of electronics.   Two tiny vocal cords tucked safely within the larynx vibrate to create the human voice. 

I brushed up on the basics of voicing when a young lady e-mailed me seeking voice therapy. She was experiencing vocal fatigue and hoarseness. I recommended that an otolaryngologist examine her vocal cords and that she follow through with any referral to a speech language pathologist (SLP) specializing in voice therapy. However, I also suggested we meet for a voice screening and a consultation regarding normal voice production and good vocal hygiene. At our first meeting, we talked about her concerns and completed both the Voice Activity and Participation Profile[1] and the Consensus Auditory-Perceptual Evaluation of Voice[2]. In subsequent sessions, we talked over her vocal history, demands currently placed on her voice, and some thoughts on change. I enjoyed these conversations.

Updating my knowledge of voice and voice therapy was a welcome change of pace. The American Speech Language Hearing Association studies that caught my eye questioned the usefulness of vocal warm-up[3], studied the significance of speaker temperament[4], and recommended ‘motivational interviewing’ as a method to support change[5].  YouTube had several relevant videos.  There were animations of laryngeal and related anatomy and physiology[6]. There was a 4-part power point presentation narrated in detail by Stephen M. Tasko, Ph.D., CCC-SLP.[7] Miriam van Mersbergen, Ph.D., CCC-SLP talked about the “Basics of Voice Training” in a video produced by LinguaHealth.[8]  The National Center for Voice and Speech had a tutorial explaining how researchers have come to understand vocal fold function.[9] And, there were lots of videos of the vocal cords recorded using videostoboscopy. It was all so fascinating that I also purchased a 6-hour continuing education course![10]

Here’s a very short synopsis.  Air from the lungs pushes the vocal cords apart, increasing the space between them. A combination of aerodynamics and vocal cord elasticity causes them to move back toward one another, closing the airway. It is a continuous stream of air from the lungs that separates the vocal cords again and again and again, resulting in a “non-linear mucosal wave.”  Puffs of air explode through the opening between the vocal cords and breeze through the throat, mouth and nose before leaving the body.  This air is shaped into speech sounds along the way.

I was happy enough with that review.  Except the continuing education course placed such emphasis on diaphragmatic breathing, that I researched this too.  A careful search of YouTube uncovered videos about breathing that seemed useful for a wide range of clients. How the body works: breathing was a delightfully simple animation with the sound muted. The narration is a bit technical and bland for children.[11]  A white board presentation by a young woman offered more complex information with friendly enthusiasm.[12] An authoritative and quite professional looking animation was available for studious teens and adults.[13]  Finally, that priceless podcast series, Stutter Talk, had at least two episodes devoted to breathing and speech.[14],[15] I assembled a new webpage for voice almost instantly![16]

Some occupations demand a clear, professional sounding voice. People who depend on their voice to earn a living include singers, politicians, broadcasters, actors, salespersons, customer service workers and teachers.  For these workers, vocal pathology is an occupational hazard.  They need to take excellent care of their voices and actually, many of them do even more. They study articulation (including accent reduction), intonation, loudness, pausing/phrasing, vocabulary, and the difference between explicit and implied meaning. SLPs treat a variety of voice disorders due to medical conditions. However, they also train use and care of the professional voice.

I have a renewed appreciation for the role of breath support in communication. I almost never talk about breathing with my students because they usually respond with effortful thorasic or clavicular breathing.[17]  Observe yourself taking “a deep breath.” What do you do? Do your shoulders rise up and your chest expand? They shouldn’t, at least not by much. It’s your abdomen that should expand as your diaphragm presses downward to make extra space for the lungs. How many of us ever learned this? A newspaper advertisement for a local performing arts school shows a little girl being taught diaphragmatic breathing as she sings.  This seemed exceptional. My curiosity got the best of me and I purchased a how to sing DVD by an internationally known singer. It instructed me in a series of fast-paced vocal exercises with slight reference to diaphragmatic breathing. I had to wonder how many viewers of this DVD damaged their voices by trying to sing using the laryngeal muscles instead of adequate breath support.

The concept is simple. Physical work requires effort and that effort can be misplaced. For example, I am learning to play the piano. My fingers are uncomfortable at the piano keys. With every missed note, my arms and shoulders stiffen and I hold my breath. Why?! I’m not entirely sure, but it happens. With the wisdom of an adult, I pay close attention to gentle breathing and upper body relaxation as I struggle to match music notes and piano keys and finger movements. I stop. I slow down. I attend to the feeling of my muscles. I have the time to do that. When voicing is difficult, speakers may compensate with extra effort in the neck, mouth, and face. It happens.[18] Conversation is fast paced and demanding so there is no time to stop, slow down, attend to the feeling of muscle movement and prevent inappropriate motor memories. (It can also be that differences in motor abilities affect this process.) Finding the feeling of relaxation under a variety of circumstances comes in handy. [19]

There it is: a brief description of voicing, which necessarily includes a review of breathing.  I am looking forward to learning alot more about the voice and voice therapies in the future.

[1] This can be found in the Appendix of Estella P-M.Ma and Edwin M-L. Yiu (2001) Voice Activity and Participation Profile: Assessing the Impact of Voice Disorders on Daily Activities. Journal of Speech Language Hearing Research, 44, 511-524.
[2] This can be found as Appendix C in G.B. Kempster et. al. (2008) Consensus Auditory-Perceptual Evaluation of Voice: Development of a Standardized Clinical Protocol. American Journal of Speech Language Pathology, 18, 124-132. The authors give permission to photocopy it for clinical purposes. When I downloaded it, the lines used for severity ratings were only 95mm long, so I retyped the entire document and drew 100 mm lines as required.Appendix A and B describe the tool, administration, and scoring.
[3] Rochelle L. Milbrath and Nancy Pearl Solomon (2003) Do Vocal Warm-Up Exercises Alleviate Vocal Fatigue? Journal of Speech, Language, Hearing Research, 46, 422-436.
[4] M. Dietrich and K. Verdolini Abbott (2012) Vocal Function in Introverts and Extroverts during a Psychological Stress Reactivity Protocol. Journal of Speech, Language, and Hearing Research, 55, 973-987.
[5] Alison Behrman (2006) Facilitating Behavioral Change in Voice Therapy: the Relevance of Motivational Interviewing. American Journal of Speech Language Pathology, 15, 215-225.
[6] Cricoarytenoid Function AngleOne 4sec http://www.youtube.com/watch?v=nhVXgDEPu1E&feature=relmfu (this is one of them)
[7] Part 1 http://www.youtube.com/watch?v=A5uW4LcAemw (this is one of them)
[8] Speech Language Pathology: The Basics of Voice Training  http://www.youtube.com/watch?v=mC2b5PxGavM&feature=youtube_gdata_player
[10] Ellen N. Friedman (2012) Short - Term Voice Therapy. 6 hour CEU course, www.pesi.com
[12] 8.6 Respiratory System Structure and Function http://www.youtube.com/watch?v=12ddbrqpZiQ&feature=related
[14] Stutter Talk:  Episode 263 The Anatomy and Physiology of Normal Speech Breathing as It Relates to Costal Breathing and Stuttering, 2/27/11,  http://stuttertalk.com/?s=breathing
[15] Stutter Talk: Stuttering and Breathing with Doctor Phillip Shneider,  Nov 8, 2008   http://stuttertalk.com/tag/breathing/


Online Conference About Stuttering

The ISAD Conference is an interactive online event taking place from October 1 - 22.  Please take advantage of this remarkable chance to chat with the authors of several papers on stuttering. There is even an Office Hours – the Prof In link at which you can post any question about stuttering. Look for the ISAD conference link by visiting the Stuttering Home Page, www.stutteringhomepage.com. I have a Clinical Nugget  this year called Fluency Lessons for Window Shopping. It is co-written with a high school student and describes our visits to local retail stores as a method of carryover of new speech skills.

As I prepared to chat with people from around the world, I reflected upon my 30 years as a speech-language pathologist. Sixteen of them were almost exclusively working with children who stutter. Why? Well, let’s begin with a memory.

My paternal grandmother died of Parkinson's when I was about nine years old.   I can close my eyes and recall her dark green home, the small galley pantry, the living room where we watched Art Linkletter’s talent show, the screened porch that wrapped around  the front of the house, the push button light switches, and the toad who lived in a hole beside the foundation. And, I recall my grandmother’s slurred and stuttered speech. The connection between the warmth I felt in her presence and my decision to specialize in fluency therapy startled me one afternoon in the 1980’s during casual conversation with an elderly woman. Long lost memories of my grandmother flooded my mind and I experienced one of those ethereal moments when one’s life seems to make sense.

Early in my career and for far too many years, I counted stuttered syllables and tried to implement highly structured and apparently logical speech therapy. I basked in the glow of hard-earned diplomas from intense and expensive higher educational institutions. Over time, I discovered that therapy was very different from classroom work and research projects. When a dedicated student experienced relapse, I was forced to question my education and my attitude. Confused and humbled, I had learned that work with clients is not described well using logic or percentages.

For licensed, certified health care professionals, the client -clinician relationship is defined by the American Speech Language Hearing Association (ASHA) Code of Ethics. (1) There are ASHA publications on recommended best practice. Continuing education and clinical practice requirements for ongoing recertification and license renewal keep professionals current.  But sometimes one wonders what is real and what is paperwork.

In the past 20 years, my own therapeutic method has become more personal at the same time in which the profession of speech language pathology moved in a different direction. The profession has become more efficient. Data collection – for the benefit of insurance and educational institutions – seem to be paramount now.  Experts continue to press for large scale research studies in stuttering to accommodate the medical trend toward evidence based practice. (2)

What influences treatment method and outcome? Research suggests there may be subtypes of stuttering. Attention deficit, phonological disorders, dyslexia and other issues can co-occur with stuttering. The transfer of more fluent speech to daily life is still the lock without a key. While the latest research in genetics is promising, how does this change the lesson plan? (3) Every client comes to therapy as a unique individual. I worry about  demands for efficiency with an emphasis on data collection because therapy is not about stuttering – it’s about people. It seems to me that any data used to promote a treatment approach would need to include detailed descriptions of the individuals for whom it was “successful.” Will that happen?

My transition to a more personal treatment approach was nurtured by conventions of the National Stuttering Association and Friends: The Association of Young People Who Stutter. Attendees at these meetings expressed frustration with speech therapy. I was taken aback, discouraged and then grateful. I would come home and listen to my clients more carefully. My lesson plans changed to be more conversational and fun. But, new referrals to my practice were confused: why didn’t I have more rigorous demands for fluent speech? They were at the beginning of a journey that I and a few other SLPs had been traveling for a while. A small group of exceedingly dedicated SLPs (I was not one of them.) established the first ASHA Specialty Commission (4) and worked hard to address the multiple issues that make for a comprehensive approach to speech therapy for stuttering.  There’s no quick fix, only a personal path of ups and downs and variable results. (5)

Now I ask about my clients’ lives and share a little of my own. Students get small prizes for just showing up. Homework expectations are replaced by congratulations for any evidence of personal responsibility. I match the efforts of my clients. Those who attended regularly and reliably receive highly individualized lesson materials.  Attention to affective and cognitive issues equal that of speech motor change. Written reports are  lengthy and include footnotes (very inefficient and time consuming!) My role is one of giving my very best to the few who are invest the same. Is this effective? Clients decide. Informal, annual data collection and ongoing conversation keep us focused on collaborative goals. Unsatisfied clients move on to other service providers.

Fluency enhancing strategies haven’t changed for many years and dissatisfaction with them has become more public. (6) I feel the most significant change has been a lowering of expectations for fluency to avoid rewarding covert behavior. This therapy option coincides with a greater appreciation of the client’s perspective, exquisitely documented in the film Transcending Stuttering (7). Treatment methods are controversial to this day, as demonstrated by articles published in 2012 issues of the ASHA journal  Language Speech Hearing Services in Schools.

Talking is different from playing the piano, hitting a baseball, or learning to read, IMHO. Speech sounds are elusive and invisible. Listeners make snap judgments about a speaker’s competence, cultural identity, and eligibility for future relationships based on how they speak. It is societal expectations that drive clients into speech therapy. A Ted Talk titled The Disabled Listener (8) extols the profound value of respectful listening.  Watch it and ask yourself how you might become a better listener.

Now the client trumps any specific treatment approach. My clients assume complete responsibility for scheduling sessions. They are equal partners in treatment design and implementation. Quite frankly, this is a horrible business model, and so,  I continue studies in the field of literacy to expand my practice caseload. The warmth I felt listening to the stuttered speech of my grandmother returns whenever I put relationship before data and (illusions of) efficiency. My small contribution to the 2012 ISAD conference reflects this commitment to the individual.

Many grateful thanks to A. C. for his contribution to this effort.

(2)   Nippold, M.A. & Packman, A. (2012). Managing Stuttering Beyond the Preschool Years. Language  Speech Hearing Services in Schools (43) p. 340.
(3)   Rowden-Racette, K. (September 18, 2012). In Search of Stuttering's Genetic Code. TheASHALeader  http://www.asha.org/Publications/leader/2012/120918/In-Search-of-Stutterings-Genetic-Code.htm
(4)   Specialty Board on Fluency Disorders http://www.youtube.com/watch?v=hrAxNijdJVY
(5)   Schnieder, P. (2004) Riding the Fluency Instability Roller Coaster. http://www.mnsu.edu/comdis/isad7/papers/schneider7.html
(6)   Voice Unearthed: Hope, Help, and Wake-Up Call for the Parents of Children Who Stutter http://www.voiceunearthed.com/  
(7)   Schnieder, P. (2005). Transcending Stuttering: the Inside Story  http://www.mnsu.edu/comdis/isad8/papers/pws8/schneider8.html
(8)   Lansing, S. E. (June 8, 2011) The Disabled Listener: They can talk, they can hear, they just don’t listen. TEDxTalks http://www.youtube.com/watch?v=hrAxNijdJVY


Bullying Prevention and Intervention Laws Could Support Children Who Stutter

 National Stuttering Association (NSA) conventions inspire me to rethink speech therapy. That’s why I love to attend. This year’s convention, held in Tampa, Florida, left me pondering how to place greater emphasis on advocacy as an essential communication skill. Advocacy goals could easily dovetail with America’s growing concern over bullying (1). New local laws in many states require school districts address this problem.

Skill at personal advocacy is a valid therapy objective. It used to be that speech-language pathologists (SLPs) focused on fluency. But success with speech change varies one person to the next and science has not yet figured out why.  In the meantime, therapy outcomes have broadened to include multiple aspects of communication.  Some SLPs take advantage of this trend to justify special education for children who stutter (CWS)(2).Others do not.  I have watched this process over the past 30 years. I witnessed and I read heated arguments between university professors over exactly what the role of the SLP should be. While this divisive dialogue drags on, what can a parent do right now to help the child who stutters?

I propose parents find out if their state has enacted a law regarding bullying.  I expect that when a parent provides the school with brochures from the Stuttering Foundation (3) AND a printout of their district’s legally mandated Bullying Prevention and Intervention Plan, we may see more CWS receive greater attention. Laws to promote a “healthy school climate” benefit all children. This means that when CWS are denied special legal protections because they are denied special education, their parents may have a legal alternative.

The 187th General Court of the Commonwealth of Massachusetts on May 3, 2010, approved “An Act Relative to Bullying in Schools.” (4) The Department of Elementary and Secondary Education responded with Bullying and Prevention Resources (5) and a Model Bullying and Intervention Plan (6).  My own school district copied this plan, adding details about specific programs (7) and the administrative hierarchy responsible for their implementation.  My district also has a District Improvement Plan that includes “Safe Learning Environment” as a target. I believe presenting this kind of information to school personnel adds weight and credibility to parents’ pleas for support for their children.

 “The finding that the risk of being bullied in adolescents who stutter is high when compared to their fluent peers should be of considerable concern. Speech-language pathologists need to be aware of this information as they often serve as the strongest advocates for students who stutter in the school setting.” (8)  Research indicates that children who stutter “are mimicked, made fun of, called names, physically bullied, and sometimes subjected to threats… It is clear that stuttering is an identifiable difference that invites bullying.” (9) This information is vital because mandatory professional development for school personnel must include “research findings on bullying, including information about specific categories of students who have been shown to be particularly at risk for bullying in the school environment…[with] a particular focus on the needs of students…whose disability affects social skills development.” (10)

Social skills development in adolescents includes “initiating interactions, self-disclosure, and intimacy in conversations and activities…assertiveness, responsiveness, and versatility. These skills allow speakers to make requests, actively disagree, express their feelings, initiate, maintain, and disengage in conversations…in multiple settings and with different conversational partners…” (11) Some school age children who stutter are at risk of falling behind in the development of these social/communicative skills because they avoid situations in which speech is difficult and in which they risk ridicule.

 “For adolescents who stutter, changing motor speech behaviors may not result in accompanying attitudinal and cognitive changes. Programs that reinforce assertiveness skills, positive communication models, acceptance of stuttering, and ways of dealing with stuttering may actually assist in dealing with potential co-occurring issues like bullying.” (12)

Again and again my students avoid advocating for themselves. How many times have I heard children say that teachers and friends understand stuttering already so there is no need to discuss it?!  Everybody knows I stutter and it’s no big deal, they say. Yet these same children report avoidance and negative attitudes on written checklists. They cry about school assignments, allow others to speak for them, ‘forget’ to talk with teachers, limit class participation and/or avoid after school activities because they are experiencing so much stress over their speech. I respond by accepting the client in the moment. But maybe a little confrontation wouldn’t hurt. Exactly how could they handle some of these problems proactively?

Has speech therapy flaunted fluency in a variety of disguises? My lesson plans involve fluency enhancing techniques, voluntary stuttering, desensitization, situation hierarchies, English Language Arts, DAF, Audacity ®, and even concepts of cognitive behavioral therapy. Do all of these perpetuate a promise that the end-goal is greater fluency? When can a CWS share personal experiences, hopes and dreams, thoughts and feelings in a friendly conversational way that would shed light on social skills competency? How can speech therapy allocate time to the complementary goals of speech change and social skills development?

 Activities which blend social skills training with speech therapy could draw from resources approved by the school district, pragmatic language therapy materials already on the SLP’s bookshelf (14), or reader-friendly publications for the layperson (15). For example, scripts and role plays [Model Plan, IV. A. p. 6] could be about a stuttering-related problem. A program specifically for stuttering is available for grades 3-6 from the University of Alberta, Edmonton, Canada. (16)  The point is to be proactive. A person who stutters has the responsibility to “be conscious that he or she has the power to promote awareness about stuttering and its ramifications.” (17) An SLP can facilitate the development of advocacy skills by making it a greater priority and interfacing with bullying prevention programs.

My friend, Marybeth Allen, ran a workshop at the NSA convention for elementary school age children. It was called “What Bugs You?” Marybeth is a Clinical Supervisor at the University of Maine, the sweetest person ever, and my roommate. As I managed a craft hot glue gun, Marybeth charmed the children into making bugs out of styrofoam containers, fuzzy sticks, pompoms, colored paper and markers. Then she gave them a small piece of paper on which to write what bugs them about stuttering. They put their hand-written complaints into the bug. Topping of the list of complaints was teasing and bullying.

New bullying prevention and intervention laws may offer CWS some well-deserved special consideration. These laws may not qualify CWS for special education services, but, hopefully they will enlighten school personnel. Sadly, a publication by National Stuttering Association written specifically for SLPs, parents, teachers, administrators, and CWS is out of print. (18) It explained issues unique to CWS.  I get the feeling that many of these children are “below the radar,” keeping their stuttering and their suffering to themselves. Let’s hope that bullying prevention and intervention programs will improve the lives of our children as depicted in this video shared on the stutt-l@googlegroups.com:

Thank you,


(1)  stopbullying.gov http://www.stopbullying.gov/

(2)  Scott, L. (2010) Decoding IDEA Eligibility. [DVD] available at www.stutteringhelp.og

(3)  Stuttering: Straight Talk for Teachers, 8 Tips for Teachers, www.stutteringhelp.org

(5)  Bullying Prevention and Intervention Resources, http://www.doe.mass.edu/bullying/#1

(6)   Model Bullying Prevention and Intervention Plan, http://www.doe.mass.edu/bullying/ModelPlan.pdf   

(7)  Open Circle: Getting to the Heart of Learning,  http://www.open-circle.org/ ;

Massachusetts Aggression Reduction Center, http://webhost.bridgew.edu/marc/

(8)  Blood, G. & Blood, I. (2004) Bullying in Adolescents Who Stutter: Communicative Competence and Self-Esteem. Contemporary Issues in Communication Science and Disorders, 31, p.76.

(9)  Langevin, M & Prasad, N.G.N. (2012) A Stuttering Education and Bullying Awareness and Prevention Resource: A Feasibility Study. Language, Speech, Hearing Services in Schools, 43, p. 345.

(10)               Model Bullying Prevention and Intervention Plan, p. 4, II.B.(iv), http://www.doe.mass.edu/bullying/ModelPlan.pdf    

(11)               Blood G. & Blood, I p. 70.

(12)               Ibid. p. 76

(13)               Massachusetts Department of Elementary and Secondary Education, Guidelines on Implementing Social and Emotional Learning (SEL) Curricula, http://www.doe.mass.edu/bullying/SELguide.pdf

(14)               I happen to own Kelly, A. (2002) Talkabout. UK: Speechmark Publishing Ltd.

(15)               Cooper, S. (2005) Speak Up and Get Along! Minneapolis, MN: free spirit publishing.

(16)               Institute for Stuttering Treatment and Research. Teasing and Bullying: Unacceptable Behavior (TAB) http://www.tab.ualberta.ca/

(17)               International Stuttering Association, Rights and Responsibilities of People Who Stutter http://www.isastutter.org/what-we-do/bill-of-rights-and-responsibilities

(18)               Flores, T. Ed. (2004 ) Bullying and Teasing: Helping Children Who Stutter , www.westutter.org


Rating Scales to Measure Change

I just read a speech/language therapy report that contained daily fluency ratings for an entire school year.  Two graphs were attached to the report, one illustrated the teacher’s ratings and one illustrated parent ratings. Quite impressive!
I used to ask parents to jot down a few notes about their children’s fluency at home. I requested they make brief videos and/or audio recordings. Very few parents did so and some were so apologetic about noncompliance that I feared I’d made matters worse. Ideally, speech therapy is supposed to keep track of speech fluency in a variety of settings; but, just how to accomplish this is a challenge.
Rating scales offer a simple way to do this. A rating scale translates a subjective judgment into a number on a continuum, say 1 – 10 for example. Some rating scales have carefully defined the numbers. I adapted this kind of rating scale to supplement my notes for almost every speech therapy session I have with every student. It is a 9-point scale originally developed to measure social interaction. (1)  Points 1-2 have this definition: “Quality of the behavior is poor; there is no evidence of a habit beginning. The quantity and duration of the examples are negligible or inappropriate.” There are five such explanations on this scale. Numbers 8-9 are defined as “Quality of the behavior is outstanding, and the behavior is used creatively in the interaction. Quantity and duration of the examples are appropriate.” I added a blank spaces to write in the behaviors being measured at each session.
There are plenty of relevant behaviors and characteristics worth measuring in the field of fluency. With respect to speech, let’s consider the child who stuttered on 20 percent of syllables in September and still stuttered on 20 percent of syllables in June. One might glance at this data and assume the child had not made any progress.  A decrease in oral-motor tension over this period of time would have been excellent progress, although invisible in a measure of percent syllables stuttered. This hypothetical child could have been experiencing tense blocks and prolongations in September but predominantly relaxed part-word repetitions in June. Let’s take a look at a few rating scales. What do they measure and how?
A rating scale may define only a few numbers along a continuum. The Test of Childhood Stuttering Observational Rating Scales measures Speech Fluency and Disfluency-Related Consequences. (2)  It has only 4 points: 0 = Never, 1 = Rarely, 2 = Sometimes, 3 = Often. There are nine items in the Speech Fluency section including descriptions of blocks, prolongations and repetitions. There are also nine items in the Disfluency Related Consequences section including secondary behaviors, avoidance, and emotional reactions. I use this scale for initial screenings and for monitoring progress. I’m not completely satisfied with the sensitivity of a 4-point scale to reflect the subtle improvements that are characteristic of fluency therapy. Note: this scale is completed by adult listeners.
I used the Assessment of the Child’s Experience of Stuttering (ACES) when it was available in a free draft version (2006). This was a lengthy, 100-item  scale divided into four sections - General Information, Your Reactions to Stuttering, Communication in Daily Situations, and Quality of Life. Each item was rated on a 5-point scale with three definitions: 1 = Always, 3 = Sometimes, 5 = Never. A student’s responses were added to determine Impact Scores that corresponded to Impact Rating definitions: mild, mild-to-moderate, moderate, moderate-to-severe, and severe. I found the ACES was sensitive to therapeutic progress for older teens. It seemed too overwhelming for my elementary school age clients. When the final revision was published commercially (3), I stopped using the draft form. Note: this scale is completed by the speaker.
Some scales define only the endpoints. The Adolescent Communication Questionnaire (12)  is a list of 39 speaking situations rated on a 5-point scale. The directions state: “How much confidence do you have about doing each of the behaviors listed below? Circle the number that best represents your confidence.” 1 = No way. I would be too uptight to speak and  5 = No problem. I would be very confident speaking. (4) Another scale that measures communication attitudes uses seven data points to measure comfort level, confidence, and feelings of success. (5) The word “extremely” appears at the extreme endpoints in one of them: 1 = Extremely Successful and 7 = Extremely Unsuccessful. Note: these scales are completed by the speaker.
There are a few qualitative differences between rating scales worth mentioning. First, for some scales (1, 4), larger values represent greater success. On others (2, 3, 5), larger numbers represent greater severity of a problem.  The Predictive Cluttering Inventory (6) uses a scale with the largest number placed on the left side of the continuum unlike all the other scales I’ve described. Second, it is very important to document who, what, when, and where every time a rating is chosen. Fluency is notorious for its variability. I think it is safe to say that no one stutters all the time in the same way. And third, without training for agreement, everyone creates their own definitions for points along the scale. (7) Very anxious parents or highly sensitive speakers may rate dysfluencies much more severely than an SLP or teacher. How about the pediatricians who counsel parents to wait and see if their toddlers will outgrow stuttering? I imagine they rate dysfluencies quite mildly.
Why use a rating scale? Besides the demand for data in our present educational system, numbers can be easier to compare over time. In the report I mentioned earlier, teacher ratings on a 10-point scale indicated stuttering decreased quite dramatically from the beginning to the end of the school year. I expect this data represents careful collaboration between the teacher and the school-based SLP. My congratulations to everyone involved in this case. It’s always a delight to discover  school district willing to help children who stutter. How can I and others adapt this kind of collaboration to meet the unique needs of other students?
One possibility is to define points along the 1-10 scale. Combined with training for listener agreement, carefully worded definitions may help us compare across listeners with some accuracy. Then we might feel more confident that a teacher rating of 7 could be the same as a parent’s rating of 7. If training is not possible, it is still helpful to pursue the question of why fluency ratings change for one listener over time. This could reveal new and/or confirm known strategies that were especially effective. This is not carefully controlled research, but I would argue it is still beneficial.
A little aside: when data is collected as part of a research study, a statistical analysis determines whether or not change is significant and not due to chance. Well-designed research has many controls in place so that experimental results confirm or deny a specific hypothesis.  For example, well-designed studies have a control group of people who receive no treatment.  If the control group does not change during the course of the experiment yet the treatment group does change after receiving treatment, one might argue that treatment was responsible for the change. Such research is difficult to do with children who stutter because it means withholding treatment for those children in a control group.
Ratings focus our attention on individual issues that affect fluency and communication.  This focus helps us to understand and control for those factors to promote greater fluency, healthy attitudes (8), and more effective communication. Let’s return to our example of measuring of stuttering frequency. Sometimes children may stutter less because they successfully generalize fluency enhancing skills and educate the listeners in their environment.  Or, it might be that greater fluency is the result of a parent/caregiver-implemented, home-based therapy plan. (9)  In these examples, everyone can feel empowered and optimistic about prognosis for improvement.
Alternately, it may be that children stutter less because they are talking less or avoiding difficult words. These are maladaptive speech/language/communication behaviors. Many experts in the field propose that it is healthier for a child to express herself freely while stuttering than to reduce verbal output for the sake of fluency.
Sometimes fluency fluctuates in conjunction with life events. Illness, fatigue, moving to a new home, family changes, academic demands, annual celebrations, and growth spurts in language development can all affect fluency. In these cases, it would be cruel to hold a child accountable for increases in stuttering. Stuttering management is a multifaceted endeavor that requires team work between parents, teachers, caregivers, SLPs and others. It is a puzzling disorder that demands patience, understanding, and kindness from everyone involved.
Here’s what I mean, an infant sibling may keep all the other family members awake at night and impatient during the day. We don’t expect a young child to automatically know how to cope in this situation. A young child is not likely to say, “Hey! Mom and dad! I need help falling back to sleep when that charming new little kiddo wakes me up with his crying in the middle of the night! And, by the way, could we schedule some more time for me!”  However, this child might have more angry outbursts, be less cooperative, and demonstrate more dysfluency instead, IMHO. Does this child need environmental management or direct fluency therapy?  Rating scales may help determine the effectiveness of the chosen treatment.
Perhaps  the older child has discovered his stuttering is affecting his grades.  He may be frustrated by failed attempts to change his speech on his own and has stopped raising his hand in class.  He might be noticing an inability to keep up with the rapid, fluent speech of his peers. This child may need a treatment plan that includes learning more about speech physiology and instructs him in ways to advocate for himself. Rating scales related to quality of life issues, self-confidence and communication attitudes could be crucial to a total treatment program. (10)
Rating scales can be a valuable asset in fluency therapy. (11) We need to consider several choices of what to measure, how to define points along the continuum, and how we expect the results to affect future treatment. I’m looking forward to using rating scales more often and more creatively in my own practice.
On a scale of 1-5 (where 1= most unsatisfactory and 5 = most satisfactory) , I hope you have a 10 kind of day!

(1)  MacDonald, J.D. & Carroll, J.Y. (1992) A Social Partnership Model for Assessing Early Communication Development: An Intervention Model for Preconversational Children. Language, Speech, Hearing Services in Schools, 23, p. 115.
(2)  Gillam, R. B., Logan, K.J., Pearson, N.A. (2009) Austin TX: PRO-ED
(3)  Yaruss, J.S., Quesall, R., Coleman, C. (2010) Overall Assessment of the Speaker’s Experience of Stuttering (OASES), Pearson Education, Inc.,  http://psychcorp.pearsonassessments.com/HAIWEB/Cultures/en-us/Productdetail.htm?Pid=PAaOASES&Mode=summary
(4)  Bray, M.A., Kehle, T. J., Lawless, K.A., Theodore, L.A., (2003) The Relationship Between Self-Efficacy to Depression, American Journal of Speech Language Pathology, 12, p. 431.
(5)  Gottwald, S.R. (2011) “Rating Scales as a Clinical Tool” http://www.mnsu.edu/comdis/isad15/papers/therapy15/gottwald15.html
(6)   Daley, D. (2007) “Cluttering: Characteristics Identified as Diagnostically Significant by 60 Fluency Experts” http://www.mnsu.edu/comdis/isad10/papers/daly10/daly10.html
(7)  One teen directed me to his favorite online comic strip, xkcd, one that poked fun at use of a 1-10 rating scale of pain. http://xkcd.com/883/  
(8)  Yaruss, J. S. & Coleman, C., Stuttering Center of Western Pennsylvania, “Helping Children Who Stutter Develop Healthy Communication Attitudes,”  http://www.stutteringcenter.org/Forms/2009-stuttering-center-parent-attitudes%20handout.pdf
(9)  Lidcombe Program, Australian Stuttering Research Center, http://sydney.edu.au/health_sciences/asrc/clinic/parents/lidcombe.shtml
(10)               Blood, G. The POWERR Game, Stuttering Foundation, http://secure.stutteringhelp.org/Merchant5/merchant.mvc?Screen=PROD&Store_Code=SFA&Product_Code=0250&Category_Code=N

(11)  O’Brian, S., Packman, A., Onslow, M. (2004) Self-Rating of Stuttering Severity as a Clinical Tool, American Journal of Speech-Language Pathology, 13, 219-226.

(12) M. A. Bray, et. al. (2003) The Relationship of Self-Efficacy and Depression to Stuttering. American Journal of Speech Language Pathology, Vol. 12, 425-431, the rating scale is on page 431.
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This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.Creative Commons License
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.