10/13/2018 Agenda • Context: WHO ‐ ICF & ABCs Cluttering across the lifespan: • Define: LCD Overview of • Assessment assessment and treatment • Treatment • Resources Jessica L. Fanning, Ph.D., CCC ‐ SLP OSHA 10/13/18 WHO-ICF: Serving entire person (Yaruss & Quesal, 2004) ABCs: Similar considerations w PWS/PWC (Yaruss, 1998) • Impairment • Affective Structure: brain, speech mechanism • feelings Function: observable disfluencies, fluency, rhythm, speed, anxiety • attitudes, experiences • Personal Factors/Reactions • coping style, temperament • Affective • Behavioral • Behavioral • Cognitive • motor behaviors, speech disfluencies • Environment (external influences on fluency) • accessory behaviors, tension • Reactions of people in person’s environment • avoidance, escape • Supports & services in person’s environment • Electronic/digital devices or tech • Cognitive • Activity limitation/Participation restriction • psychological • Speak, converse, discourse, interact, social • Interactions in education, employment, community • self ‐ evaluation Define Assessment (DX): Methods & procedures • HX: many ways to describe • Overall • Challenging in research • Video/audio ‐ record to address “normalization” • Confusing to clinicians • Frequently rely on “professional judgement” • Tasks • LCD (St. Louis & Schulte, 2011) 1. Inta 1. take background, history • Perception of rapid rate …. PLUS at least one of these: 2. Doma 2. mains to assess 1. excessive normal disfluencies 3. 3. Speech ch mod modes to include 2. excessive collapsing or deletion of syllables 4. Speech 4. ch beha behaviors to track & quantify 3. abnormal pauses, syllable stress, or speech rhythm • Note: not all speech samples need to contain evidence of speech cluttering for cluttering diagnosis 1
10/13/2018 1. Assessment: Intake 2. Assessment: Domains • Case history (as usual) • Speech behaviors • Parent/client/partner/close friend interview • Rate • Medical history, family HX • Rhythm & unusual pausing • Onset, changes, treatment • Fluency • Other challenges? • Articulation • Attention • Language • Learning • Narrative vs sentence/phrase level • Language • Attention & Auditory Memory • Questionnaires • OASES (Yaruss, Quesal, & Coleman, 2010) • Self ‐ survey checklists • KiddyCAT (Vanryckeghem & Brutten, 2007) • Predictive Cluttering Inventory—PCI (Daly, 2006) • Checklist of Cluttering and Associated Features—COCAF (Ward, 2018) • TOCS Observational Rating Scales (Gillam, Logan, & Pearson, 2009) 3. Assessment: Modalities 4. Assessment: Speech behaviors • Across modalities • Rate • Rhythm & unusual pausing 1. Conversation (~5 ‐ 10m) • Fluency 2. Oral reading (~5m) • Articulation 3. Narrative retell (~5m) • Additional • Monologue (~5m) • Expository discourse (~5m) ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ • Compare/Contrast • Sequencing, syntax, tangential, over ‐ elaborate, detail, intelligibility Assess: Speech Rate Assess: Speech Rhythm & Pausing • Subjective perception • Word stress • Increased stress on function words? • Quantify articulatory rates (sps, spm) • De ‐ stressed content words? • SPS calculation • Rapid bursts influence perception of consistent rhythm • Rapid burst & count syllables for 1 ‐ second maximum articulatory rate • Guide to “fast” articulatory rates (Van Zaalen, Wijnen, & Dejonckere, 2011a) • Any features of rhythm impacting message clarity? • Young > 5.1 sps • Any pattern to unexpected pauses? • Adolescents > 5.4 sps • Adults > 5.6 sps • SPM calculation • Speech rate might be WNL (Guitar, 2014) 2
10/13/2018 Assess: Fluency Assess: Articulation • NSLDs • SLDs • General lack of articulatory precision that is: • Blocks • Not phoneme specific & Not present in isolation or syllable level • Repetitions • Prolongations • Phrase • Co ‐ articulation is good…unless outside typical limits • Part ‐ word repetitions • Over Co ‐ articulation ”mushy, mumbly, blurry, blended” • Whole ‐ word • Whole ‐ word reps • Client age? • Omit syllables w/tension • Revisions • Weakly accented syllables = Telescoping (dinosaur “disaur”) • False start • Omit words NSLDs / SLDs • Maze • Pronouns, articles (go to the game “go to game”) • Interjections • Multisyllabic words, changing stress patterns • READ: chysthanthemum; possibilities; statistical • READ: “certify, certificate, certification”; “accumulate, accumulation, accumulating” • Ratio of NLSDs > 1.7 might indicate cluttering (Van Zaalen, Wijnin, & Dejonckere, 2009a) Other Assessment: Handwriting (Ward, 2018) Other Assessment: Checklists • Daly (2006): Predictive Cluttering Inventory (PCI) • Ward (2018): Checklist of cluttering and associated features (COCAF) Review: Current definition Differential Diagnosis (Scaler Scott & Ward, 2013; St. Louis, 2011; Ward, 2018) Context Cluttering Stuttering • LCD definition (St. Louis & Schulte, 2011) Speech rate: sounds too fast sounds interrupted • Rate: _______________ Disfluency ratios: NSLDs > SLDs SLDs > NSLDs • Plus at least one more… Blocks Phrase Rep 1. Excessive _____________________________ Prolongations Whole ‐ word Reps w/o tension Disfluency types: Part ‐ word reps Interjections 2. Excessive _____________________________ whole ‐ word Reps w/tension Revisions 3. Abnormal _____________________________ Articulation clarity: omit syllables, words no omissions, but interrupted Rhythm, Pauses: unexpected accelerated bursts interruptions Word, syllable stress: unexpected stress errors typical but interrupted Fluency (“normalization) Fluency In pressure situations (i.e., DX) Important note: _____________________ In more relaxed & casual conversation (i.e., not Cluttering Stuttering self ‐ monitoring speech) Across lifespan, self ‐ awareness Can be low Rarely low for speech challenges 3
10/13/2018 Review: ABCs of Cluttering After DX…moving toward TX • Affective • Completed DX using ICF framework & ABCs • feel: frus frustrated, embarr embarrassed ssed, una unaffect ected • Speech function • attitudes & experiences: tir tired of of “w “wha hat? t?”; wh why don’ don’t people people under understand nd me? me? • Personal factors • coping style, temperament: individual • Environmental supports • Behavioral • Activities & Participation • speech disfluencies: NSL NSLDs • Analyze & interpret • accessory behaviors, tension: not not ex expecting th these unl unless ess st stutter ttering ng al also so pr presen esent • Prioritize goals across domains w client & family: • avoidance, escape: not not ex expecting th these unl unless ess st stutter ttering ng al also so pr presen esent • Speech functions (rate, rhythm, fluency…) • Cognitive • Language & learning features (organization, sequencing, word ‐ finding…) • psychological: individ ndividual • Attention & Self ‐ regulation factors (self ‐ awareness, self ‐ regulation, self ‐ monitoring) • self ‐ evaluation: possi possibly bly lo lower/harder fo for PW PWC Treatment (TX): Methods TX: Overall hierarchies to consider • Overall • easy—hard; short—long; simple—complex; fast—slow; low—high • Linguistic • Hierarchies • Cueing, Support • Features • Speech modality • Procedures • Interest 1. Principles to guide procedures that you choose • People 2. Targets • Setting, Situation 3. Cluttering & Stuttering (PWC/S) • Speech sounds 4. Cluttering + Co ‐ occurring • Strategies TX: Overall features (Bennett, 2011; Langevin & Boberg, 1996; Scaler-Scott & Ward, 2013; St. Louis, 2011) 1. TX: Principles to guide procedures (Bennett, 2011) • Education & shared understanding • Therapy should: • Teach clients the language of fluency • Motivational Interviewing (Miller & Rollnick, 2013) for natural refinforcers & • Help the client understand dimensions of own cluttering meaningful goals for best progression • Encourage & teach self ‐ monitoring • Get support system going • Include activities initiated with clear rationale for each task • Functional & fun • Use routine that follows consistent routine & sequence of practice • Setup cueing system • Incorporate repetitive practice w/variety of tasks • Incorporate concrete & conceptually ‐ based activities • Treat stuttering if necessary ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ • PWS/C: Start where there is most impact to communication & confidence (likely start w FS strategies either way) 4
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