Winter 07/08

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University of Central Florida ... you afraid to raise your hand to talk in class). .... University of Texas at El Paso; her master's degree from Texas Tech University,.

People Who Stutter: A View from Within

Martine Vanryckeghem University of Central Florida The core issue of this paper relates to whether or not we, as clinicians, have the necessary data available to say with confidence that the person being evaluated is one who stutters. This determination is not easily made with anything that approaches certitude. In part, this is because it is clear that a person who stutters (PWS) is more than one who is dysfluent. The disruption of fluency is not the exclusive response province of PWS. People who do not stutter (PWNS) also evidence dysfluency, sometimes to an extent that exceeds that of individuals seen as PWS. Moreover, fluency failure, even the forms that are considered characteristic of those who stutter, is not the only element that sets them apart from other dysfluent speakers. Fluency can be disrupted as a result of various disorders that range from neurological degenerative disease or lesion to psychological trauma (Baumgartner, 1999; Helm-Estabrooks, 1999). Fluency disruption may also be related to cluttering and to such genetic syndromes as Gilles de la Tourette, Down, and Asperger. The question is what, if anything, sets the dysfluencies that result from these disorders apart from each other, from developmental stuttering, and from normal disfluency. Research has made it evident that a count of fluency failures, even of those whose description has been greatly elaborated (Bloodstein, 1995, p.1), is an insufficient and unreliable basis to diagnose whether or not someone is a PWS (Bloodstein, 1995; Hegde, 1996; Ingham & Cordes, 1992; Perkins, 1990; Silverman, 2004). Disagreement exists between listeners, even fluency experts, as to the presence or absence of stuttering moments. The lack of inter- (and often intra-) judge reliability is but one reason why a mere count of dysfluencies is not a valid basis to diagnose stuttering. Another reason is that persons who stutter are characterized by more than the presence of excessive speech disruption or particular forms of dysfluency. There is more to being a stutterER than stutterING (Brutten & Vanryckeghem, 2003a, 2003b, 2007a; Conture, 2001; Guitar, 2006; Perkins, 1990; Silverman,




2004; Smith & Kelly, 1997). Validly viewing a person as one who stutters requires that his or her dysfluencies are accompanied by particular feelings, behaviors and attitudes that sets them apart (Cooper, 1999). In essence then, the observation of the type, number and duration of dysfluencies is an insufficient means of determining whether or not a person is the one who stutters. Though seemingly objective, it is unreliable and thus invalid. It provides a very limited picture of what characterizes and distinguishes the PWS. In recent years, clinicians and therapists have looked for a broader view of what defines a PWS, one that includes a “view from within” (Brutten & Vanryckeghem, 2003a, 2003b, 2007a). In part, this is a result of the recognition that we should not ignore stutterers’ perception of their own stuttering (Bloodstein (1990; Riley, 1994) because only they can validly determine the presence of fluency failure (Perkins, 1990). In this vein, a recently published assessment tool helps make a more complete and valid assessment of the PWS possible.

The Behavior Assessment Battery The Behavior Assessment Battery (BAB) (Brutten & Vanryckeghem, 2003a, 2003b, 2007a) provides the clinician information that aids in the evaluation of individuals whose fluency is considered problematic. The BAB is a multidimensional and evidence-based set of interrelated test procedures that are useful in diagnostic and therapeutic decision making for children and adults who stutter. It has been standardized, normed, and subjected to decades of internationally-based research and peerreviewed reports (see Brutten & Vanryckeghem, 2003a, 2003b, 2007a for a review). The BAB consists of the Speech Situation Checklist, the Behavior Checklist, and the Communication Attitude Test. The Speech Situation Checklist has two sections. Section I is designed to assess a person’s negative emotional reaction to particular speech situations and Section II is designed to investigate speech disorganizations that these situations tend to elicit. The Behavior Checklist gauges the number and types of responses the PWS may employ to cope with the anticipation or presence of speech disruptions. Finally, the Communication Attitude Test explores an individual’s speech-associated attitude. Together, the three assessment tools tap into affective, behavioral, and cognitive dimensions that help make a precise and accurate diagnosis of stuttering. The BAB results also serve to highlight a client’s needs and, as such, give direction to therapy.

Over the years, the BAB tests have been changed or adjusted based on feedback from therapists and clients. Applied researchers have made clear their validity and reliability. They have been shown to have content and criterion validity (Brutten & Vanryckeghem, 2003a, 2003b, 2007a; DeKort, 1997), are made up of items that are internally reliable, and have significant test-retest reliability (Brutten & Dunham, 1989; Brutten & Vanryckeghem, 2003a,b, 2007a; De Nil & Brutten, 1991; Ezrati-Vinacour & Levin, 2004; Vanryckeghem & Brutten, 1992). The Emotional Reaction (ER) section of the Speech Situation Checklist (SSC) investigates the extent to which a child or adult experiences negative feelings (concern, anxiety, fear of talking) in particular speech situations. The children’s form of the SSC-ER contains 50 items that relate to speech situations that are relevant to their world (e.g. Because of your speech, are you afraid to raise your hand to talk in class). Similarly, items from the ER section of the adult form of this test relate to situations that they are likely to meet (e.g. “Are you anxious, concerned, or worried about your speech when you are ordering in a restaurant?”). On both the children and adult form of the SSC, the negative affect typically elicited by particular speech situations is measured along a 5-point Likert type scale ranging from “no” or “not at all” to “very much.” The Speech Disruption (SD) section of the children and adult forms of the Speech Situation Checklist explores the extent to which speech disruption is experienced (defined as silent and oral sound, syllable, and word repetitions and sound prolongations) in the very same settings described in the ER section of this test form. A 5point Likert scale is employed to determine the reported extent to which these settings set the occasion for dysfluency. Though the ER and SD sections are administered at different times, they have been shown to correlate highly (.82 and .78) for stuttering children (Brutten & Vanryckeghem, 2003a, 2007a) and adults (.87) (Brutten & Vanryckeghem, 2003b). This relationship has also been made evident by Ezrati-Vinacour and Levin’s (2004) data which showed that there was a statistically significant correlation between SSC-ER and judged stuttering severity during reading (.89) and conversation (.88). These data point to an inter-relationship between negative emotion and speech disorganization and suggest a “loop” (Neale & Liebert, 1986, p.13) relationship, one in which each of these variables may be causally related to the other. It is well known that PWS employ various behaviors to help them cope with their speech disruption. Purposive behaviors of this kind, ones used to avoid anticipated stuttering or to escape the occurrence of speech disruption, are People who Stutter continued on page 10

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CSHA Magazine 9

Dear CSHA members, As you are making your plans to attend the CSHA convention in Monterey in April, don’t forget to bring along new elementary-aged children’s books promoting literacy (books, book marks, book lights) to donate! This is an exciting opportunity to support the student drives and give to those who are in need. If you are coming from far away and are limited in the items you can carry into the convention but would still like to make a donation, we will gladly accept gift cards for bookstores. Donated books will be distributed The Reading Center of CSU Monterey Bay promoting literacy. Bring these items to student table located outside the exhibit hall and show your support! Another opportunity to give back to the community is available; the CSHA board sponsors a drive to collect cell phones for victims of domestic abuse. Bring along your old cell phones and accessories to donate for this great cause. If you have questions or would like more information about the student drives, feel free to contact the CSHA student representatives. annual_convention.htm


Susan Yao-Tresguerres, Northern California Student Representative [email protected]

Brianne Bricker, Southern California Student Representative [email protected]


CSHA Magazine


People who Stutter continued from page 9

inventoried in the Behavior Checklist (BCL). The children’s form of the BCL contains 50 such behaviors that are secondary to stuttering, while the adult form describes 95 coping behaviors that involve bodily movements or are related to respiration, phonation or articulation, and verbal events. The children are merely asked to indicate by YES or NO whether they employ the particular coping behaviors listed on the BCL as a means of helping them speak. In addition, the adults are asked to indicate the scaled frequency with which they typically use the coping behaviors of avoidance and escape that they report (Brutten & Vanryckeghem, 2003a, 2003b, 2007a; Vanryckeghem, Brutten, Uddin & Van Borsel, 2004). The Communication Attitude Test (CAT) explores a child’s belief system about speech and the act of speaking. It taps into the child’s speechrelated attitude. The CAT and Communication Attitude Test for Adults (BigCAT) (Brutten & Vanryckeghem, 2007b) are similar in that they require the clients to indicate whether the attitudes described (e.g., I talk well most of the time) represent what they think about their speech. The CAT has been extensively researched crossculturally since its first publication in 1989. Its validity and notably high internal and test-retest reliability has been well documented (Brutten & Dunham, 1989; Brutten & Vanryckeghem, 2003a, 2007a; DeKort, 1997; De Nil & Brutten, 1991; Ezrati & Sagi, 1992; Vanryckeghem & Brutten, 1992). Moreover, the data stemming from internationally-based investigations have consistently shown that the speech-associated attitude of children who stutter (CWS) is significantly more negative that that of those who do not stutter (CWNS) ( Brutten & Vanryckeghem, 2003a, 2007a; De Nil & Brutten, 1991; Jaksic-Jelcic & Brestovci, 2000; Vanryckeghem & Brutten, 1992, 1997). In addition, negative attitude has been shown to relate to other dimensions of the stuttering syndrome that are measured by the BAB (Brutten & Vanryckeghem, 2003a, 2007a). For example, it has been shown that the attitude of those who stutter is highly related (.89) to their emotional reaction (Vanryckeghem, Hylebos, Brutten & Peleman, 2001) and correlates significantly with observed dysfluency during oral reading and conversation as well as with clinician ratings of stuttering severity (Vanryckeghem & Brutten, 1996). Research has also repeatedly shown that, as early as the age of six, CWS have significantly more in the way of a negative speech-associated attitude than CWNS. Moreover, with age, CWS show an increase in mal-attitude toward their speech whereas the limited negativity decreases among CWNS (Vanryckeghem & Brutten, 1997). The extent of this between-group difference led to the development of the KiddyCAT (Vanryckeghem & Brutten, 2007), a test procedure that makes it possible to study the communication attitude of children younger than

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six. It is made up of 12 items (e.g., Is talking hard for you?) that are presented to the child orally and require a “Yes” or “No” answer. Research with the different BAB tests has consistently shown that children and adults who stutter score statistically higher on its measures than those who do not stutter. Specifically, speech-related negative emotional reaction and attitude, speech disruption, and the extent to which coping behaviors are used are all elevated to a statistically significant extent among adults and children who stutter compared to their nonstuttering peers. Of particular importance are the KiddyCAT results which indicate that, as early as three or four, CWS show the presence of a negative speech-related attitude that is different from that of CWNS (Vanryckeghem & Brutten, 2007; Vanryckeghem, Brutten & Hernandez, 2005). The presence of mal-attitude at this young age is of critical importance, especially when we consider the data of Grinager, Ambrose, and Yairi (1994) and Ezrati-Vinacour, Platzky, and Yairi (2001) indicating an awareness of speech disruption by the age of three. These findings call attention to the need for early detection of a negative belief system in our evaluation of the incipient CWS and the importance of addressing attitude in treatment early on. The comparison of a client’s total test score to the norms for children and adults who do not stutter as well as those who do, provides the clinician with evidence-based data relative to selfexperienced speech-associated phenomena and serves as an aid in differential diagnosis. Furthermore, the separate test scores provide information about the different dimensions of the disorder that warrant attention in therapy. The BAB tests present an inventory of speech situations that elicit fearfulness, speech disruption, coping behaviors, and/or negative beliefs that need to be dealt with in treatment. As such, the responses to the BAB tests provide a direct link to intervention by pointing to the specific targets that need to be addressed. It allows for individualized goal setting for a therapy tailored to the specific needs of a particular client. In addition, follow-up test administration offers feedback on the specific effect of therapy and helps decide whether or not adjustments need to be made to the goals set and the therapy procedures being utilized. N

References Baumgartner, J. (1999). Acquired psychogenic stuttering. In R. Curlee (Ed.), Stuttering and Related Disorders of Fluency, pp. 269-288. New York: Thieme. Bloodstein, O. (1990). On pluttering, skivering, and floggering: A commentary. Journal of Speech and Hearing Disorders, 55, 392-393. Bloodstein, O. (1995). A handbook on stuttering (5th ed.). San Diego, CA: Singular Publishing Group.

People who Stutter continued on page 20


r. Karen Jones Howard Green is retiring after 40 years off work in speech pathology and education. She has worked in public schools, four universities in two states and a practice. She received her bachelor’s degree from the University of Texas at El Paso; her master’s degree from Texas Tech University, and her doctorate from the University of Houston. She is also a Registered Professional Education Diagnostician in Texas.


Dr. Green served on the first Licensure Board in the state of Texas and the ASHA Continuing Education Board. She ends her career at California State University Northridge and was the first coordinator of the innovative online distance education masters degree.

Dr. Karen Jones Howard Green

Dr. Green received a Certificate of Appreciation from the Texas Speech-Language-Hearing Association and Abilene Christian University. She received an Outstanding Award for Service to California Speech-Language-Hearing Association, District 7. She also received the Don Dorsey Award for Mentoring Excellence at California State University Northridge. She has received five Awards for Continuing Education from ASHA. Her presentations have included topics on distance learning, learning disabilities, innovative university classes, treatment in an adolescent psychiatric facility, inservice training for the regular education teacher, private practice, teacher beliefs concerning mainstreaming, and language performance of Anglo and Mexican-American children. N

People who Stutter continued from page 10 Brutten, G., & Dunham, S. (1989). The Communication Attitude Test: A normative study of grade school children. Journal of Fluency Disorders, 14, 371-377. Brutten, G., & Vanryckeghem, M. (2003a).

Behavior Assessment Battery: A multi-dimensional and evidence-based approach to diagnostic and theapeutic decision making for children who stutter. Belgium: Stichting Integratie Gehandicapten & Acco Publishers. Brutten, G., & Vanryckeghem, M. (2003b).

Behavior Assessment Battery: A multi-dimensional and evidence-based approach to diagnostic and theapeutic decision making for adults who stutter. Belgium: Stichting Integratie Gehandicapten & Acco Publishers. Brutten, G. & Vanryckeghem, M. (2007a). Behavior Assessment Battery for children who stutter. San Diego, CA: Plural Publishing, Inc. Brutten, G. & Vanryckeghem, M. (2007b).

BigCAT: Communication Attitude Test for Adults who Stutter. Unpublished manuscript. Conture, E. (2001). Stuttering: Its nature, diagnosis and treatment. Boston, MA: Allyn and Bacon. Cooper, E. (1999). Is stuttering a speech disorder? ASHA, 41,10-11. DeKort, C. (1997). Validity measures of the Communication Attitude Test. Unpublished Master’s Thesis. University of Alberta, Edmonton, Canada. De Nil, L., & Brutten, G. (1991). Speechassociated attitudes of stuttering and nonstuttering children. Journal of Speech and Hearing Research, 34, 60-66. Ezrati-Vinacour, R. & Levin, I. (2004). The relationship between anxiety and stuttering: a multidimensional approach. Journal of Fluency Disorders, 29, 135-148. Ezrati-Vinacour, R., Platzky, R. & Yairi, E. (2001). The young child’s awareness of stutteringlike disfluency. Journal of Speech, Language and


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Hearing Research, 44, 368-380. Ezrati, R. & Sagi, Y. (1992). The relation

between negative communication attitudes, severity of stuttering and years of stuttering in stuttering children at school age. Unpublished bachelor’s degree paper, Tel Aviv University, Tel Aviv, Israel. Grinager Ambrose, N. & Yairi, E. (1994). The development of awareness of stuttering in preschool children. Journal of Fluency Disorders, 19, 229245. Guitar, B. (2006). Stuttering: An integrated approach to its nature and treatment (3rd ed.). Philadelphia: Lippincott Williams & Wilkins. Hegde, M. (1996). Pocket guide to assessment in speech-language pathology. San Diego: Singular Publishing Group, Inc. Helm-Estabrooks, N. (1999). Stuttering associated with acquired neurological disorders. In R. Curlee (Ed.), Stuttering and related disorders of fluency (pp. 255-268). New York: Thieme. Ingham, R. & Cordes, A. (1992). Interclinic differences in stuttering-event counts. Journal of Fluency Disorders, 17, 171-176. Jaksic Jelcic, S., & Brestovci, B. (2000). Communication attitudes of children who stutter and those who do not. Journal of Fluency Disorders, 25, 208. Neale, J. & Liebert, R. (1986). Science and

Behavior: An introduction to methods of research (3rd ed.). Englewood Cliffs, NJ: Prentice-Hall. Perkins, W. (1990). What is stuttering. Journal of Speech and Hearing Disorders, 55, 370-382. Riley, G. (1994). Stuttering Severity Instrument for Children and Adults (3rd ed.). Austin, Texas: Pro-Ed. Silverman, F. (2004). Stuttering and other fluency disorders (3rd ed.). Englewood Cliffs, NJ: Prentice Hall. Smith, A. & Kelly, E. (1997). Stuttering: A dynamic, multifactorial model. In R. F. Curlee & G.M. Siegel (Eds.), Nature and treatment of

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stuttering: New directions (2nd ed.) (pp. 204-217). Needham Heights, MA: Allyn & Bacon. Vanryckeghem, M., & Brutten, G. (1992). The Communication Attitude Test: A test-retest reliability investigation. Journal of Fluency Disorders, 3, 177190. Vanryckeghem, M. & Brutten, G. (1996). The relationship between communication attitude and fluency failure of stuttering and nonstuttering children. Journal of Fluency Disorders, 21, 109-118. Vanryckeghem, M., & Brutten, G. (1997). The speech-associated attitude of children who do and do not stutter and the differential effect of age.

American Journal of Speech-Language Pathology, 6, 67-73. Vanryckeghem, M. & Brutten, G. (2007). The KiddyCAT: A speech-associated attitude test for preschoolers and kindergartners. San Diego, CA: Plural Publishing, Inc. Vanryckeghem, M., Brutten, G. & Hernandez, L. (2005). The KiddyCAT: A normative investigation of stuttering and nonstuttering preschoolers’ speech-associated attitude. Journal of Fluency Disorders, 30, 307-318. Vanryckeghem, M., Brutten, G. & Uddin, N. & Van Borsel, J. (2004). A Behavior Checklist comparative investigation of the speech-associated coping responses of adults who do and do not stutter. Journal of Fluency Disorders, 29, 237-250. Vanryckeghem, M., Hylebos, C., Brutten, G., & Peleman, M. (2001). The relationship between communication attitude and emotion of children who stutter. Journal of Fluency Disorders, 26, 1-15. Send correspondence to: Martine Vanryckeghem, Ph.D. Department of Communication Sciences and Disorders University of Central Florida 4000 Central Blvd. Suite 101 Orlando, FL 32816 [email protected]