A stuttering evaluation consists of a review of the client's history relevant to their stuttering, a description of the current status of their stuttering, a cursory assessment of other communicative abilities (voice, articulation, language, and hearing) (more in depth if they contribute to stuttering), evaluation of the functioning of the oral peripheral mechanism, and a summary of the findings. Minimally, the purpose of the initial evaluation is to gather basic demographic information, establish a diagnosis, document baseline dysfluency data and agree upon a future course of action.

The information offered below details the segments of the evaluation.

Background Information: The objectives of the background section of the assessment are to:

	Trace facets of the history and development of the stuttering
	Learn how stuttering affects the client
	Determine what's been done to change the stuttering (past therapies, techniques, etc)
	Find out how the client perceives his or her stuttering
	Learn the reason the client has sought to do something about his or her stuttering at this time and their expected outcome of today's session
	Determine the client's understanding and objectivity toward their stuttering

This information is gathered in an interview format in which the clinician asks questions and probes the client with the goal of ascertaining specific facts involved in their stuttering. The following list of questions should be considered as a framework from which to probe clients to elicit the desired information. Remember that each client is different and each interaction with any given client will differ. It is up to the clinician to interact with and lead the client in order to garner the necessary facts and the client's perceptions.

Typical questions might include the following:

	What brings you here today? (What are you looking for us to do to assist you?)
	When did your stuttering begin? (At what age did it start?)
	How has it changed since it began? (Determine stuttering's course of development)
	Does anyone else in your family stutter? (Is there a family history of stuttering?)
	Have you ever gotten help for your stuttering before? (What's been tried; how successful was it; why didn't in continue to work?)
	What physically happens when you stutter? (How well can the client objectively describe the parameters of his or her stuttering?)
	Are there particular sound or situations that you find difficult? (Are there fearful factors or situations that the client has learned?)
	What do you do to help yourself in these situations? (Can the client do something that is helpful or does he or she find themselves a victim of their stuttering?)
	What do you think causes your stuttering? (Determine what the client knows -- or thinks they know -- about stuttering)

Note the stuttering behaviors he or she exhibits in responding to your questions. The background information usually takes about 10-15 minutes to gather in the initial segment of the assessment. Remember that the client has told you how to "satisfy" them at this initial meeting. Be sure to orient your summary of the evaluation at the end of the session toward answering the client's specific reason for coming even if that's not the most "professionally" significant assessment finding.

Stuttering

The fluency section describes the attributes of the client's stuttering behaviors, rates severity, describes maladaptive speaking behaviors and probes stuttering's handicapping affects to the client. Evaluation of each component is described below:

	Stuttering Behaviors: Enumerate all core stuttering behaviors (blocks, repetitions, prolongations, and tremors) observed during the session; provide an approximate prevalence of each behavior noted.
	Secondary Characteristics: describe all bodily movements, interjected sounds, avoidance and escape behaviors, and "non-speech" components associated with stuttering
	Severity of Stuttering: Using the Riley Stuttering Severity Instrument (SSI), rate the severity of the client's stuttering. There are three components to the SSI -- a count of the client's disfluencies in spontaneous speech and in reading, the duration of their three longest disfluencies, and a rating of distractibility of secondary behaviors. [Note: The SSI-3 tallies disfluencies at the syllable, rather than the word level. While more sensitive to changes in stuttering than the SSI, the additional time required to analyze the speech sample using the SSI-3 may not be justified, particularly in light of other variables unaddressed by either version of the assessment tool.] Videotape a 150-word spontaneous speech sample; try to elicit the sample without needing to interrupt or question the client in order to have them speak 150 words. Next, have the client read a 150-word passage, taking care to select a passage that will not challenge the client's reading ability.
	Maladaptive Behaviors: Note any usual or effortful speaking behaviors evidenced during the speaking samples and previous conversation. Such behaviors may include rapid rate of speaking, excessive muscular tension in the lips or tongue when articulating sounds, hard glottal attacks, loss of eye contact, pauses and hesitations, interjection of extraneous sounds or phrases ("you know", "like"). While not exhaustive list of possible behaviors, these are perhaps the most common.
	Handicapping Affects: Discussion of how the client copes with his or her stuttering may be elicited by asking questions such as, "How do you think your life would be different if you didn't stutter?" The clinician seeks to determine the accommodations the client makes because of his or her stuttering. A handicap is defined as what the client does or does not do solely because of his or her stuttering.

Clients are asked to try a variety of speech therapy techniques, based upon the symptoms of stuttering they exhibit or the philosophical orientation of the clinician. This experimentation serves as a likely starting point for therapy. Determine the client's most frequent stuttering behavior and select a fluency target that enables them to change or compensate for the dysfunctional aspects of their dysfluency.

Link to "Speech Therapy Techniques"

Note the techniques the client was able to use successfully and did not express reservation using. For some clients, this will be their first experience in being able to exert any degree of control over their stuttering. This can be very exciting and the foundation of hope for their future. Client's usually express reluctance to use slow rate as a technique outside of the therapy room. It is generally unwise to attempt to convince them of the virtues of speaking at a slow rate during the initial session; generally clients discover it on their own at a later point in their therapy.

Articulation

An experienced clinician will note the presence of misarticulated sounds in the client's conversational speech. If none is noted, there is not need to administer a formal articulation test. The clinician simply notes that "No significant misarticulations were noted in the client's conversational speech."

If some sounds are misarticulated, a formal articulation test is administered to inventory errant sounds. If English is not the client's native language, vowel production should also be assessed. The Goldman-Fristoe Test of Articulation or the Arizona Test of Articulation are common choices. Because articulation tests are commonly developed for children, their stimulus pictures are also 'childlike'. A brief explanation to clients about the drawing's simplicity is usually sufficient to avoid 'offending' adult and adolescent clients.

Many people who stutter have difficulty with confrontational naming tasks such as those required in articulation testing. The purpose is to evaluate production of a specific sound, not to name the stimulus word. With that in mind, the client may be allowed to substitute another word with the sound in the same position. Note the sounds which seem to elicit stuttering responses; you may later determine that certain sound production categories (such as plosives) tended to be stuttered on with more regularity by the client. Remember, with adults, age norms are not meaningful -- they should have mastered all phonemes.

Some clients have "slushy" or "sloppy" articulation skills. The articulation of specific sounds may not be "bad", but the overall quality of the ability to move the articulators is poor. For these clients, their oral motor abilities may be suspect and may contribute to their stuttering. A client's articulation ability is generally a good indicator of the functional ability of their oral peripheral structures.

Voice

Clinicians must be cognizant of the parameters of normal voice production: pitch, intensity, quality, nasality and resonance. When noted in clients who stutter, voice disorders are most often unrelated to their stuttering. There are however, several parameters related to voice that are commonly seen in people who stutter. They are described below:

	Ineffective Breathstream Management: Rapid inhalation of air or gasping, or speaking on residual air
	Abrupt Vocal Onset: Beginning phonation abruptly rather than softly and smoothly; typically with excessive force
	Hard Glottal Attack: Phonation begins with the vocal folds forcibly held together; usually there is a failure to release any exhalated air before adducting the vocal folds to initiate phonation
	Pitch Rise: As a block continues, the client's pitch fluctuates (usually rises) as they attempt to force their way through a block
	Loud Voice: The byproduct of effortful speaking attempts
	Soft Voice: May reflect fear or lack of confidence in speaking

Many of the therapy techniques for stuttering specifically address these voicing parameters. Consequently it is important to be familiar with them.

Language

The clinician gets a general sense of a client's communication skills by how well they are able to put their thoughts into words and follow the conversation. Clients demonstrating functional abilities to express themselves and understand what is said to them usually do not require further specific language testing. Assessment of language skills in adults (who have not suffered a stroke or other neurological insult) is generally a matter of some subtlety. It is thought that language impairments are present among adults who stutter no more than the general population. (However, it has been reported that 24% of children who stutter have concomitant speech and/or language problems.) Certainly word-finding difficulties may distract from the overall fluency of a client's speech. However, many clients who stutter substitute another word for one they think they will have difficulty saying. As a result, their communication may sound awkward or is frequently revised to accommodate their avoidance strategy. Additionally, many people aren't willing participants in conversation and don't provide much opportunity to informally assess their language abilities.

The dilemma then is 'what to test'?

	Vocabulary Development: The Peabody Picture Vocabulary Test (while dated) does not require a verbal response and also provides estimated IQ information, which for some clients, may have prognostic value.
	Word Finding: The Naming subtest (Section IV, B Word Fluency) of the Western Aphasia Battery may provide a rough indication of the client's convergent word-finding abilities. Responses can be written instead of spoken.
	Sentence Formulation and Syntactic Development: Elicited in a writing sample; have the client write a brief essay or describe a picture.

Clients who present with a neurogenic incident in their history may require more testing specific to areas of possible language and cognitive impairment. Stuttering evidenced subsequent to neurological trauma is substantially different than developmental stuttering in its symptoms and treatment.

Hearing

Hearing ability is best evaluated using an audiometer and a sound booth. Impaired hearing acuity is not commonly related to stuttering, so functional measurement is sometimes adequate for purposes of the fluency evaluation. The clinician may get hints of hearing impairment by a client's frequent requests for information to be repeated or his or her misunderstandings in conversations.

To administer a functional hearing test, the clinician conceals of their mouth from the client's view with a paper or other object. The client is asked to repeat numbers or letters presented by the clinician in a whispered voice. The clinician includes a "trick" word in the series of number or letter presentations… "Six… three… nine….. seven….. elephant". By using an item outside the expected 'data set', the client's ability to use guessing as a means of responding is frustrated.

People who stutter do not demonstrate hearing loss with greater frequency than the general population. However, some research tends to indicate that the auditory processing ability of people who stutter differs significantly from people who do not stutter.

Note: Periodic hearing testing is an important part of responsible hearing care. Many people suffer form chronic middle ear infections, have a history of exposure to noise or have difficulty understanding others in noisy environments. Referral for an auditory assessment may help remediate these difficulties for clients.

Oral-Peripheral Examination

Structural abnormalities are not commonly associated with stuttering and therefore are no more likely to be found among people who stutter than the general population.

A client's articulation ability is generally a good indicator of the functional ability of their oral peripheral structures. In particular, listen for the 'crispness' of sound production and for inconsistent articulatory placements as indicators of potential decrements of function. The client's stuttering often impairs the clinician's ability to assess functional speech. Some use of excessive effort in articulation sounds is associated with stuttering.

Rate of speaking may be another issue. When assessing rate, consider that each individual has an optimal speed at which the articulators function accurately. The clinician can judge whether the client's habitual speaking rate exceeds their optimal speed.

Another measure of functional rate is diadochokinetic rate testing. For many clients who stutter, stuttering impedes diadochokinetic testing for reasons similar to that of confrontational naming tasks. If the client has difficulty with "pataka", try "buttercup" or another multi-syllabic word. Actually counting syllable rate production is less important than gleaning a feeling of the synchrony and coordination of the mechanism. In my experience, there is little 'middle ground'. Either the client 'has it', or they don't.

Introduce each sound individually; have them repeat "pa" as rapidly as they can for at least 20 seconds. Do the same for "ta" and then "ka". Note their ability to maintain continuity of movement at rapid rate. Be mindful of disfluencies. Next, ask the client to repeat the entire sequence, "pataka", as rapidly as they can for at least 20 seconds. Again, counting is of minimal importance compared to the integrity of movement.

"Slushy" articulation, drooling, problems with saliva control or 'messy' oral habits (such as eating) at present of in the client's past, brings delayed or disordered oral motor function under suspicion.

The Summary Interview

At the conclusion of the evaluation the clinician has the opportunity to communicate several important pieces of information to the client. You recall that the minimal components of the initial evaluation are to gather basic demographic information, establish a diagnosis, document baseline disfluency data and agree upon a future course of action.

The demographic information is usually obtained on the Clinic registration form. In a brief time, the clinician usually is able to establish the diagnosis of stuttering (primarily for insurance purposes). The clinician reviews with the client during the summary interview, the components of the client's stuttering that were observed during the assessment, along with an explanation/description of each one. Additional information about the course of stuttering's development, cause, or other pertinent information is communicated. It is critically important to respond directly to the purpose the client initially expressed as their reason for seeking the evaluation. This provides closure for the client and usually is the beginning of a new set of questions yet to be addressed. The final feature of the evaluation is to recommend a course of action for the future. The client is entitled to the clinician's best advice and direction in resolving the problem(s) presented during the assessment. After making recommendation(s), the clinician discusses with the client their options and assists them in making a decision about a course of action to pursue.

The evaluation report is another opportunity for the clinician to communicate the results of the assessment. Usually there is too much information to successfully communicate orally to the client. The written report presents all assessment findings, interpretations, and recommendations. As a consequence, the clinician may highlight the most critical findings and recommendations during the summary interview, rather than attempting to give a comprehensive oral report of the assessment. The written report also is the clinician's legal document of their findings and a tool used to communicate with other professionals.