CMD460 fluency disorders

fluency

the term describes speech that is easy, rapid, rhythmical and evenly flowing- all speakers are disfluent at times (typical disfluencies)

fluency disorder

an interruption in the flow of speaking characterized by atypical rate, rhythm, and disfluencies and other behaviors

two types of fluency disorders

stuttering and cluttering

stuttering 

most common fluency disorder, interruption in the flow of speaking characterized by specific types of disfluencies including: repetition of sounds, syllables and monosyllabic words (look at the b-b-baby), prolongations of consonants when it isn’t for emphasis (sssssometimes we stay home), blocks (inaudible or silent fixation of inability to initiate sounds) 

the stuttering disfluencies can affect

the rate and rhythm of speech and may be accompanied by negative reactions to speaking, avoidance behaviors, escape behaviors and physical tension

guitar three-part definition

characterized by an unusually high frequency or duration of repetitions, prolongations and/or blockages that interrupt the flow of speech - the interruptions are often combined with excessive mental and physical effort to resume talking, most stutters have negative perceptions of their communication abilities

people who stutter often experience 

psychological, emotional, social and functional consequences from their stuttering, social anxiety, a sense of loss of control, negative thoughts/feelings about themselves or communication 

95% of children who stutter start before the age of

4, more prevalent in boys than girls

onset may be 

progressive or sudden 

approximately 88-91% of children who show disfluencies will

recover spontaneously with or without intervention

stuttering can co-occur with other disorders like

ADHD, ASD, intellectual disability

incidence 

the number of new cases identified in a specific time period 

prevalence

the number of individuals who are living with fluency disorders in a given time period

estimates of both incidence and prevalence both vary due to several factors

disparities in the sample populations, how stuttering was defined, how stuttering was identified

approximately 2% of children ages 

3-17 years stutter 

recovery rates were estimated to be

88-91%

increased incidence among those with a

first degree relative who stutter

children with a family history were estimated to be 

1.89 times more likely to persist in stuttering 

typical disfluencies at age 2 & 3

whole-word repetition (i-i-i want a cookie), interjections (can we-um-go now?), syllable repetitions (i like ba-baseball), revisions (he cant - he wont play baseball)

normal disfluencies do not tend to

affect the continuous forward flow of speech

disfluencies that involve within-word disruptions

tend to be judged as stuttering by listeners

core behaviors 

on the other hand the primary stuttering behaviors are disfluencies which are not typical 

early stuttering 

speech of preschoolers is often marked by disfluencies: due to the difficult motor patterns that must be refined during speech development, repetition of the first word in sentences is the most common form, the amount of disfluency declines over time for the majority of children, some children show increased disfluencies with atypical disfluency types 

a warning sign

an average of 3 or more within-word disfluencies (sound repetitions, prolongation, blocks) per 100 words

stuttering children might show feelings of frustration about their speech and begin to develop

secondary stuttering behaviors

a predisposition for stuttering may be 

inherited 

signs and symptoms of stuttering - core speech behaviors

monosyllabic whole-word repetitions (why-why-why did he go there?), part-word or sound/syllable repetitions (look at the b-b-boy; ba-ba-ba-baseball), prolongation of consonants when it isnt for emphasis (sssssometimes we stay home), blocking (inaudible or silent fixations), production of words with an excess of physical tension or struggle, clustered disfluencies (when the instance contains more than one type of within-word disfluencies m-m-m-mmmmmommy)

avoidance or escape behaviors

secondary characteristics or accessory behaviors

secondary characteristics or accessory behaviors 

behaviors often used unsuccessfully to stop or avoid stuttering - using fillers (like, um, uh), avoiding sounds or words (substituting words, inserting unnecessary words), altering rate of speech 

other observable secondary stuttering behaviors can include

body movements (head nodding), facial grimaces and distracting sounds (throat clearing) - behaviors often used unsuccessfully to stop or avoid stuttering

secondary characteristics become

automatic, less successful, and distracting over time

efforts to conceal stuttering may 

adversely affect quality of life 

onset and development of stuttering occurs between 2 & 5

75% of the risk of developing stuttering occurs before the cild is 3 1/2 years old, gradual onset and slowly increasing severity overtime for majority of children

stuttering does not always develop gradually

for some individuals when stuttering is first diagnosed in young children, the symptoms appear to be very advanced and secondary characteristics may be present

individual variability 

the manner, frequency and context one stutters might be different from another stutterer 

stutterers emotional aspect

have negative concepts of themselves as a communicator

stutterers linguistic aspect

stutter on long words, complex sentences, words critical to the communication context

stutterers motor aspect

have difficulty in their motor system that interferes with their ability to react rapidly (less efficient motor system) 

stutterers have more

right hemisphere activity than nonstutterers

cause of stuttering are thought to be

multifactorial

stuttering often beings when

childrens language abilities are rapidly expanding

as children produce longer and more complex sentences, their brain 

experiences higher demand, which affects the motor control necessary to produce speech 

stuttering can occur when

motor pathways cant keep up with language signals

imbalance between the demands for fluency and the childs capacity to produce fluent speech might

cause disfluency

negative emotions may place an additional cognitive burden on children who

stutter during a critical period of language development 

genetic factors

studies support a genetic predisposition for stuttering, no specific gene but gene mutations have been linked to stuttering (NPTAB, GNPTG, NAGPA), genetics can predict the likelihood of persistence or recovery and possibly treatment

structures and functional neurological difference can be shown in

children who stutter

reduced left gray matter volume with reduced white matter integrity in the left hemisphere in  

children with persistent stuttering 

reduced neural network connectivity in areas that support the timing of movement control

may affect speech planning needed for fluency

more right hemisphere activity with less activity in the left hemisphere in

adults and children who stutter

linked to speech production 

reduced regional blood flow in brocas area

stuttering resolves a lot in childhood, resolution is related to

growth spurts in developmental domains - speech motor control, language, cognition, temperament

chronic stuttering might include factors of

negative feelings and attitudes (frustration and embarrassment), avoidance (avoiding difficult words and situations), difficulties with speech motor control (unusual patterns)

risk factors associated with persistent stuttering - sex of child 

boys are at higher risk than girls

risk factors persistent stuttering -  time durations 

of greater than 6-12 months since onset of no improvement over several months 

age of onset

children who start studying 3 ½ years or later

when does an SLP conduct a comprehensive assessment

disfluencies are noted, family history of stuttering, patient concern, person exhibits negative reactions to their disfluency, person is experiencing negative reactions. from others

comprehensive assessment components  

relevant case history, consultations with family members and educators regarding fluency variability, review of previous fluency evaluations and educational records, assessment of speech fluency 

comprehensive assessment may result in 

diagnosis of fluency disorder, differential diagnosis between fluency disorders and other speech/language disorders, descriptions of the characteristics and severity of stuttering, degree of impact stuttering has on verbal communication and quality of life

impact social and emotional

having conversations or telling stories; forming friendships; regulating emotions; showing confidence

impact academic

reading aloud; answering questions in class; giving class or work presentations; participating in class discussions

most individuals who stutter demonstrate both

observable disfluency and negative life impact 

when developing treatment goals the clinician 

takes a holistic approach and considers the extent to which stuttering affects the individuals entire communication experience 

treatment goals

focus on minimizing negative reactions to stuttering and difficulties communicating in various speaking situations

preschool children who stutter

approaches are individualized based on childs needs and family communication patterns

treatment approaches for preschoolers - indirect treatment 

focuses on counseling families about how to make changes in parents and childs environment, reducing the communication rate, using indirect prompts rather than direct questions, rephrasing to model fluent speech or technique  

treatment approaches for preschoolers - direct treatment

focuses on changing the childs speech and attitudes and beliefs in order to manage stuttering or facilitate fluency, include speech modification and stuttering modification strategies to reduce disfluency rate, physcial tension and secondary behaviors

school-age children, adolescents and adults who stutter treatment

increasing effective and efficient communications, increasing acceptance and openness with stuttering, reducing secondary behaviors and minimizing avoidances, improving social communication

successful stuttering management in adults have been described with

self-acceptance and fear reductions, unrestricted interactions, a sense of freedom, optimism, continued management 

treatment approaches for school-age children, adolescents and adults  should include a plan for 

generalization and maintenance of skills 

many clinicians use an ______ to achieve optimal outcomes

integration of approaches

two strategies addressing the impairment in function

speech modification (younger and milder) and stuttering modification (older)

reatment approaches for school-age children, adolescents and adults  increasing speech efficiency 

reducing word avoidance 

strategies for reducing negative reactions - personal and environmental context

awareness, desensitization, cognitive restructuring, self-disclosure and support

SPEECH modification strategies

include techniques aimed at making changes to the timing and tension of speech production or altering the timing of pauses between syllables and words

speech modification strategies examples 

easy/gentle onset (the gradual onset of voicing, on initial vowels), light articulatory contact (using easy articulatory gestures), continuous phonation (maintaining voicing throughout utterance), prolonged syllable (stretching syllable), rate control (slowing)

strategies aimed at altering the timing of pauses are used to

increase the likelihood of fluent speech to improve overall communication skills and to control rate

STUTTERING modification strategies 

involve changing only the stuttering behaviors, aim to reduce physical tension and struggle by recognizing behaviors, locating point of tension

primary goal of stuttering modification strategies

to help stutterers acquire a speech style they find to be acceptable (make the stutter more manageable)

stuttering modification strategies belief

attitudes and feelings about stuttering play a critical role in the development, continuation and remediation of stuttering

stuttering modification strategies: cancellation

after a stuttered word, speaker pauses to examine physical features of word and then adjusts airflow voicing and the vocal tract to produce an easy version of the word

stuttering modification strategies: pull out 

during a stuttering word speaker “slides out” of stuttered word by adjusting airflow, voiding, and the vocal tract to stutter smoothly through the word 

stuttering modification strategies: preparatory set

anticipates a moment of stuttering before it occurs and use stuttering modification strategies to more effectively manage the moment of stuttering while producing the word