BEHAVIOR ASSESSMENT BATTERY: EVIDENCE- BASED APPROACH TO THE ASSESSMENT AND TREATMENT OF CHILDREN WHO STUTTER

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1 Section 6. Temperament, Attitude, and Behavior of PWS 209 BEHAVIOR ASSESSMENT BATTERY: EVIDENCE- BASED APPROACH TO THE ASSESSMENT AND TREATMENT OF CHILDREN WHO STUTTER Martine VANRYCKEGHEM Department of Communication Sciences and Disorders, University of Central Florida SUMMARY The self-report measures that make up the Behavior Assessment Battery (BAB) for children have been internationally investigated and shown to be reliable and valid test procedures. The cross-cultural data relative to emotional reaction to and speech disruption in speech situations (Speech Situation Checklist), coping behaviors used (Behavior Checklist) and speech-associated attitude (Communication Attitude Test and KiddyCAT) are in overwhelming agreement. They indicate scores that differentiate CWS from CWNS on each of the BAB test procedures. The BAB tests are useful as an aid in differential diagnostic decision making and allow for identification of treatment targets. 1. Introduction As Silverman (2004) has stated "two people viewing an event are unlikely to abstract the same attributes of it and are therefore unlikely to describe it in the same way" (p.10). This assertion certainly holds as far as dysfluency is concerned. It has been documented time and time again that different observers will likely look at people who stutter (PWS) in different ways and pay attention to different components of the disorder. Moreover, even when observing the same phenomena, such as frequency of stuttering, the inter-rater agreement is often far from optimal even among trained listeners and so called specialists. The unreliability in the molar count of stuttering moments has been described in the literature by Adams (1976), Ingham and Cordes (1992), MacDonald and Martin (1973), Tuthill (1940), among others. The lack of between- and within-listener agreement also exists in the identification and locus of stuttering. A lack of a well established operational definition of what defines stuttering is at the base of the unreliability and questionable validity of the measurement of stuttering severity. Reliability would be greatly improved if a more precise molecular definition of stuttering were to be utilized when analyzing this speech disorder. Greater than the problem of the unreliable count of stuttering is the fact that the evaluation of a fluency disorder should be part of an assessment that looks beyond the presence of speech disruption. The assessment needs to involve elements such as: an individual's background and experience history, feelings about and attitude toward speech, an account of speech-related experiences in particular situations and the use of behaviors that are accessory to the speech problem, among other things. In other words, the assessment of a PWS needs to go beyond stuttering and involve the stutterer (Bloodstein, 1995; Conture, 2001; Cooper, 1999; Manning, 2001). It needs to be multi-dimensional in order to move away from what Conture (2001) describes as a "tunnel vision view" (p.126). This can be done best by questioning the stutterer directly about his or her speech disruption. This was clearly stated by Perkins (1990) who wrote that what defines stuttering is experiential rather than observable. The empirical information can only be gleaned through the eyes of the PWS, by obtaining a 'view from within'.

2 210 Research, Treatment, and Self-Help in Fluency Disorders: New Horizons 2. Behavior Assessment Battery (BAB) The need for standardized assessment and treatment tools that incorporate a PWS's affective, behavioral and cognitive accounts has been recognized in recent years by fluency specialists. However, very few tools were available to the professional that incorporate the viewpoint of the person who stutters. The Behavior Assessment Battery (Brutten, 1973; Brutten & Vanryckeghem, 2003a, 2003b, 2007) highlights the multi-dimensional facets of the stutterer by means of an 'inner view' provided by the PWS, whether an adult or a child. More specifically, as part of a larger assessment procedure, the self-report tests that make up the BAB provide the clinician with an interrelated overview. They allow for an inside view of a person's affective reactions to sounds, words and speech situations; give an account of the extent to which particular situations occasion speech disruption; the number and type of coping behaviors used to avoid and escape speech trouble; and one's belief about speaking ability. The evidence-based data that underpin the BAB and the combined information stemming from each of these standardized tests aid the clinician in differential diagnostic decision making as to whether or not a person is a stutterer, has the characteristics of someone whose speech is not clinically significant or whose dysfluencies are of a neurogenic or psychogenic nature. For the purpose of this paper, the BAB for children will be discussed. It is composed of the Speech Situation Checklist (Emotional Reaction and Speech Disruption section), the Behavior Checklist and the Communication Attitude Test. 3. Speech Situation Checklist (SSC) The Speech Situation Checklist has two components. The first one (Emotional Reaction: ER) assesses speech-specific negative emotional reaction (such as fear, anxiety, worry, concern) in interpersonal speech settings (e.g., talking to someone you don't know) and to specific sounds/words (e.g., giving your name). The second section of the SSC (Speech Disruption: SD) evaluates the amount of speech disruption (described in terms of part word repetitions and sound prolongations - silent and oral) in the same speech situations. The SSC for children lists 55 speech situations. The children's reactions are measured on a 5-point scale. In the ER section children are to indicate their emotional reaction that can range from 'not afraid' to 'very much afraid'. The 5-point scale for the SD section ranges from 'no trouble' to 'very much trouble' talking. After summing the client's ratings for each of the sections, the outcome is compared with the norms provided in order to determine if the child's score is typical of a nonstuttering child (CWNS) or atypical and clinically significant. Several investigations have pointed out that CWS score significantly higher than CWNS on the SSC (Brutten & Vanryckeghem, 2003a, 2007; Trotter, 1983; Vanryckeghem & Verghese, 2004). The scores on each of the SSC sections should be compared in order to see if they are correlative or widely separate. Typical for the CWS is that both test sections are elevated and highly correlative. In addition, in order to get an overall impression of a child's level of emotional reaction and amount of speech disruption, particular attention needs to be paid to those speech situations that received a score of 3, 4 or 5 on the Likert type scale. This provides the clinician with more than a 'global' knowledge that a child's emotional reaction and speech disruption is atypical; it provides for an inventory of those speech situations that the child reports being fearful of and having trouble speaking in. The item analysis will give the clinician information about the specific cues (e.g., particular sounds/words, the school situation, inter-personal speech situations) that elicit speechassociated fear for a child and disrupt his or her fluency. It also serves to highlight treatment targets, the situations that need to be addressed in order for speech to be less fearful and less problematic. The SSC has shown to have a high internal reliability. All Cronbach alpha correlation coefficients were.95 and higher (Brutten & Vanryckeghem, 2007). In addition, it can be said that the test items represent an adequate sample of the phenomenon they are meant to characterize and, as such, have content validity. The items are internationally representative and based on the reports of children who stutter from a large number of clinical files in diversely situated clinics, over a time span of 50 years. The two sections of the SSC not only correlate significantly with each other (.82) but also

3 Section 6. Temperament, Attitude, and Behavior of PWS 211 with the other tests that make up the BAB, indicating the important inter-relationship among the BAB tests. 4. Behavior Checklist (BCL) The Behavior Checklist provides information about the client's speech-associated coping behaviors that are specific to sounds/words and situations. The children's form of the BCL lists 50 behaviors that might be associated with or are exhibited during the act of speaking to avoid or escape negatively charged sounds/words or speech situations. It explores the number and type of coping behaviors that a child employs as a means of dealing with the anticipation or occurrence of speech disruption. The inventory lists behaviors such as body movements (e.g., close your eyes), behaviors that are related to breathing (let some air out before starting to speak) or that are speech-specific (e.g., change sounds or words). The child is asked to indicate whether or not he or she uses some of these behaviors 'to help sounds or words come out' by indicating 'yes' or 'no' to each behavior that is described. The total score on the BCL reflects the number of different coping behaviors that a child reportedly uses. As is the case for the other tests that make up the BAB, the BCL's test items are representative of coping behaviors that children who stutter have reported and have been shown to use. The inventory of statements has been put together based on the clinical files of a large and diverse group of CWS. Moreover, the test has a good internal reliability. The Cronbach alpha reliability coefficients were.83 and.85 for CWS and CWNS, respectively (Brutten & Vanryckeghem, 2007). As is the case for adults who stutter (Vanryckeghem, Brutten, Uddin, & Van Borsel, 2004), the BCL data clearly point to the fact that the number of different coping behaviors used is significantly greater among CWS than among CWNS (Brutten & Vanryckeghem, 2003a, 2007; Vanryckeghem & Herder, 2004). Moreover, CWS and CWNS tend to use different types of coping behaviors. Stuttering children, unlike those who are normally fluent, typically use 'speech helpers' that involve manner of speaking (e.g., letting some breath out before talking, changing the loudness or rate of speech, adding a sound before a word). Once more, as with the SSC, an individual's BCL score needs to be evaluated relative to the norms for CWNS and CWS to determine if it falls within the range that is typical of CWNS or deviates to the extent that it is atypical and approximates, meets or exceeds that of CWS. Here again, it is recommended that the child's BCL score be evaluated in relation to the other BAB test data. In addition, the child's report relative to the individual BCL items provides the practitioner with an inventory of the type of escape and avoidance behaviors that are being used. It can be determined if these behaviors, ones that are secondary to stuttering, are predominantly adjustments that are particular to sounds/words, to situations or to both. The BCL inventory can be employed to further explore the information about a client's coping behaviors and the frequency of their use. 5. Communication Attitude Test (CAT) The third component of the BAB, the Communication Attitude Test investigates a child's speech-associated belief system. This latest addition to the BAB for school-age children (Brutten, 1984; Brutten & Dunham, 1989) has been field researched on an international scale. Its translation into more than 15 languages has resulted in cross-cultural research whose data have been overwhelmingly in agreement. This 'true - false' scale has been shown to have good reliability in terms of both test-retest (.83) (Vanryckeghem & Brutten, 1992) and internal reliability (.83 and up) (Brutten & Vanryckeghem, 2007). Over the years, item-to-total score data have led to the removal of two of the original 35 items because they did not correlate significantly with the test's total score (Brutten & Dunham, 1989; Brutten & Vanryckeghem, 2003a, 2007; De Nil & Brutten, 1991). The CAT's current 33 items (e.g., I talk well most of the time) are representative of children's speech-associated belief systems. They were obtained from the clinical files of school-age children who stutter and, as such, can be said to have content validity. In addition, the CAT has been shown to have criterion-related validity

4 212 Research, Treatment, and Self-Help in Fluency Disorders: New Horizons (Vanryckeghem, Hylebos, Brutten & Peleman, 2001) and scores that correlate significantly with the other tests that are part of the BAB (Brutten & Vanryckeghem, 2003a, 2007). As has been mentioned, international investigations with the CAT have resulted in normative data that have repeatedly shown the presence of a notable between-group difference. As of the age of six, CWS have significantly more in the way of a negative belief system about their speech than their nonstuttering peers do (Boutsen & Brutten, 1990; Brutten & Vanryckeghem, 2003a, 2007; DeKort, 1997; De Nil & Brutten, 1991; Ezrati & Sagi, 1992; Jaksic Jelcic & Brestovsci, 2000; Johannisson & Wennerfeldt, 2000; Vanryckeghem & Brutten, 1992, 1997). This between-group difference serves to help the clinician in determining whether or not a child's speech-associated attitude is more like that of a CWNS or a CWS. In addition, in separating out those statements that are associated with a negative attitude from those that evoke a positive attitude, the clinician can build upon the positive beliefs for the development of an attitude that helps produce, support and maintain improvement. 6. KiddyCAT As indicated, the CAT has repeatedly shown that, as of the age of six, children who stutter have a speech-associated attitude that is significantly more negative than that of their nonstuttering peers. Moreover, with age, the negative attitude of CWS becomes more negative whereas the attitude of the CWNS becomes more positive (Vanryckeghem & Brutten, 1997). Given these data and the fact that stuttering has its onset between the ages of two and five, there was a need for developing a means of investigating the speech-related belief system of children even younger than six in a way other than asking the parents (Vanryckeghem, 1995). This led to the development of the KiddyCAT, a Communication Attitude Test for preschool and kindergarten children who stutter (Vanryckeghem & Brutten, 2007). The KiddyCAT can be used with children between three and six. The 12 items of this test procedure are verbally presented to the child. Six items if answered 'yes' and six if answered 'no' are indicative of a negative speech-associated attitude (e.g., Is talking hard for you?). The KiddyCAT has content validity as the items came from statements that have been made by preschoolers and kindergartners who stutter about their speech. Moreover, it has been shown to have good internal reliability (Cronbach alpha =.75). The KiddyCAT, the first standardized test procedure of its kind, has proven capable of distinguishing the speech-associated attitude of normally fluent children, as young as three, from that of youngsters who are incipient stutterers (Vanryckeghem & Brutten, 2007; Vanryckeghem, Brutten & Hernandez, 2005). CWS score statistically significantly higher on the KiddyCAT than do CWNS. Moreover, the large effect size (1.44) highlights the considerable extent to which group membership accounts for the difference in speech-associated attitude. As is the case with the BAB tests for schoolage children, the results of this self-report test will help the clinician in determining if a youngster's speech-related attitude is typical of what is usually observed among CWNS or clinically significant and more like that of CWS. 7. Summary The BAB test procedures provide the therapist with a view from 'within the child' with respect to the situations that elicit negative emotion and occasion speech disruption, the behaviors of avoidance and escape that are used to cope with stuttering, and the presence of mal-attitude toward his or her speech. In light of considering the individuality of each child who stutters (Van Riper, 1982), the BAB results provide the clinician with an initial road map to therapy that is client specific, tailored to the child's individual needs, multi-dimensional and evidence-based. Each of the tests highlights a different component that needs attention in therapy. The SSC allows the practitioner to rank order the speech situations that elicit negative emotion and/or speech disruption. The test provides a good starting point for graduated practice in and outside the clinical setting. The BCL gives an inventory of those behaviors that are secondary to stuttering, can call more attention from listeners than stuttering itself does, interfere with communication and impede fluency improvement. Finally, the negative statements about speech and speech ability, made evident by the CAT and

5 Section 6. Temperament, Attitude, and Behavior of PWS 213 KiddyCAT, highlight a child's negative attitude toward his or her speech, beliefs that must necessarily be modified for fluency to be improved and maintained. The BAB has been subjected to international investigations. The reliability, validity and normative data that stem from cross-cultural research have been in significant agreement. Time and again, the data have pointed to scores that significantly distinguish CWS from CWNS. In addition, the test battery shows the inter-correlation between the affective, behavioral and cognitive components tested by the BAB. Not only is the BAB a helpful tool in determining whether or not a child's test score is like that of a child who is normally fluent or is atypical and like that of a CWS, its test items provide indicators that give direction to therapeutic intervention. They lay out the road map that highlights the targets of therapy. References Adams, M. (1976). Some common problems in the design and conduct of experiments in stuttering. Journal of Speech and Hearing Disorders, 41, 3-9. Bloodstein, O. (1995). A handbook on stuttering (5 th ed.). San Diego, CA: Singular Publishing Group. Boutsen, F., & Brutten, G. (1990). Stutterers and nonstutterers: A normative investigation of children's speech-associated attitudes. Unpublished manuscript, Southern Illinois University at Carbondale. Brutten, G. (1973). Behaviour assessment and the strategy of therapy. In Y. Lebrun & R. Hoops, (Eds.), Neurolinguistic approaches to stuttering (pp. 8-17). The Hague: Mouton. Brutten, G. (1984). The Communication Attitude Test. Unpublished manuscript. Brutten, G., & Dunham, S. (1989). The Communication Attitude Test: A normative study of grade school children. Journal of Fluency Disorders, 14, Brutten, G., & Vanryckeghem, M. (2003a). Behavior Assessment Battery: A multi-dimensional and evidence-based approach to diagnostic and therapeutic 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 therapeutic decision making for adults who stutter. Belgium: Stichting Integratie Gehandicapten & Acco Publishers. Brutten, G., & Vanryckeghem, M. (2007). Behavior Assessment Battery for children who stutter. San Diego, CA: Plural Publishing, Inc. Conture, E. (2001). Stuttering: Its nature, diagnosis and treatment. Boston, MA: Allyn and Bacon. Cooper, E. (1999). Is stuttering a speech disorder? ASHA, 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). Speech-associated attitudes of stuttering and nonstuttering children. Journal of Speech and Hearing Research, 34, 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. Ingham, R., & Cordes, A. (1992). Interclinic differences in stuttering-event counts. Journal of Fluency Disorders, 17, Jaksic Jelcic, S., & Brestovci, B. (2000). Communication attitudes of children who stutter and those who do not. Journal of Fluency Disorders, 25, 208. Johannisson, B., & Wennerfeldt, S. (2000). Intensive stuttering therapy for children: A comparative and descriptive study of stuttering in children who have received or applied for the therapy. Unpublished Master's thesis, Goteborg University, Sweden. MacDonald, J., & Martin, R. (1973). Stuttering and disfluency as two reliable and unambiguous response classes. Journal of Speech and Hearing Research, 16, Manning, W. (2001). Clinical decision making in fluency disorders (2 nd ed.). San Diego, CA: Singular Thomson Learning. Perkins, W. (1990). What is stuttering? Journal of Speech and Hearing Disorders, 55,

6 214 Research, Treatment, and Self-Help in Fluency Disorders: New Horizons Silverman, F. (2004). Stuttering and other fluency disorders (3 rd ed.). Long Grove, IL: Waveland Press. Trotter, A. (1983). A normative study of the Speech Situation Checklist for children. Unpublished Master s Thesis, San Diego State University at San Diego. Tuthill, C. (1940). A quantitative study of extensional meaning with special reference to stuttering. Journal of Speech Disorders, 5, Van Riper, C. (1982). The nature of stuttering (2 nd ed.). Prospect Heights, IL: Waveland Press. Vanryckeghem, M. (1995). The Communication Attitude Test: A concordancy investigation of stuttering and nonstuttering children and their parents. Journal of Fluency Disorders, 20, Vanryckeghem, M., & Brutten, G. (1992). The Communication Attitude Test: A test-retest reliability investigation. Journal of Fluency Disorders, 3, 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, 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, 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, Vanryckeghem, M., & Herder, C. (2004). Normative investigation of speech-associated coping behaviors of children who do and do not stutter. ASHA Leader, 9, 101. 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, Vanryckeghem, M., & Verghese, S. (2004). The Speech Situation Checklist: Comparative investigation of children who do and do not stutter. ASHA Leader, 9, 104.

Assessing the Affective, Behavioral, and Cognitive Dimensions of Stuttering in Young Children

Assessing the Affective, Behavioral, and Cognitive Dimensions of Stuttering in Young Children Barbara Mathers-Schmidt, Ph.D., CCC-SLP Western Washington University Barbara.Mathers-Schmidt@wwu.edu It has