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., no link
(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,” broken link
(9) Lidcombe
Program, Australian Stuttering Research Center, link has changed
(10)
Blood, G. The POWERR Game, Stuttering Foundation, broken link
(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.
(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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