Speech Disorders FINAL Exam

Disfluency Types:

Stuttering

Acquired (neurogenic) Stuttering

Psychogenic Stuttering

Cluttering

Stuttering begins…

In childhood, no known cause

Acquired (neurogenic) stuttering results from…

Brain trauma, disease, meds

Psychogenic Stuttering results from…

Emotional or psychological trauma

Not all disfluency is stuttering, not all stuttering is disfluency

Disfluency Definition

Repetitions, hesitations, and disruptions in the forward flow of speech

Everyone is disfluent sometimes

Stuttering Definition

Abnormally high frequency and/or duration of stoppages in the forward flow of speech

• Inner feeling of loss of control

• Often accompanied by secondary behaviors

Primary/Core Stuttering Behaviors

Repetitions (sounds/syllables, words, phrases are repeated)

Prolongations (sound is elongated)

Blocks (no sound is produced)

Secondary/Accessory Stuttering Behaviors

Eye aversion

Avoidance

Verbal interjections

Abnormal head or body movements

Circumlocution

Word substitution

Fluency-Enhancing Conditions

Singing or whispering

Speaking in a different voice, accent

Choral reading, talking in unison

Talking when alone, to babies or pets

Speaking to a metronome, AAF

Possible Explanations for Fluency-Enhancing Conditions

Distraction

Altered social dynamics

Rate (slower rate = more fluency)

Different self-monitoring

using speech mechanism differently

Represent situations in which person has stuttered before and associated with embarrassment or shame

Anxious feelings increase stress and resulting muscular tension

Genetic Theory

Stuttering stems from hereditary, genetic component

Twin studies: monozygotic twins have higher concordance than dizygotic twins

Family studies: genes linked to dopamine receptors and lysosomal storage

Genes interact with environmental factors

Genetic Influence

4 genes have been identified that account for ~20% of cases of persistent stuttering

Polygenetic disorder: diabetes, Alzheimer’s, schizophrenia

Diagnosogenic Theory

Behaviors the child exhibits are mostly hesitations and repetitions normally seen in all children

Parents react with increased criticism and punishment

Parents mislabel normal disfluencies as “stuttering” → make child self-conscious → child tries to avoid disfluencies → more negative reactions → stuttering

Etiology of Stuttering

Arises from complex dynamic interactions between internal factors and external conditions

Internal Factors:

Inherited traits, temperament, cognitive abilities, language abilities, information processing mechanisms, speech motor control abilities

External Conditions

Culture, dynamics of home life, child rearing practices, educational experiences, social relationships

Normal Disfluencies

Increase in children around 2 to 3 years

Revisions, pauses, interjections, effortless repetitions of phrases and words

Normal disfluencies persist throughout life: interjections, repeating, revising

Stuttering Characteristics

Sound/syllable, monosyllabic word repetitions

Sound prolongations

Within-word pauses

• Tense pauses and hesitations

Blocks

Internal feeling of loss of control

Often effortful/tense

Onset of Stuttering

Between 2 and 4 years in ~95% of cases

Mean age of onset: ~34 months

Development of Stuttering

Usually gradual

Severity often increases as child ages

~50%: at least on physical concomitant (visible tension, irregular breathing, head movements)

Some kids learn to hide it so severity appears to decrease with age

Common speech/language disorder that coexists with stuttering in children

Phonological impairment

Stuttering Impact

W.H.O.: look beyond disfluencies to client’s personal reaction, environmental reactions, participation restrictions and activity limitations

Can have negative affect on daily activities (school performance, employment, social interactions)

Can profoundly affect an individual’s self-confidence, self-esteem

Common myths about stuttering

People who stutter are more introverted

People who stutter are more anxious

Parents of children who stutter are more anxious

People who stutter have lower intelligence

People who stutter have less self-confidence

People who stutter are more sensitive

Communication with a person who stutters

Maintain normal eye contact

Do not interrupt

Do not finish their words, sentences

Pay attention to what the person is saying, not how they’re saying it

Be aware of how common stereotypes may be influencing your opinion of the person who stutters

Two Main Questions at Onset

1. Is my child stuttering

   1. Diagnosis: either yes or no

2. Does my child need treatment

   1. Prognosis: less clear cut, depends on many factors

Evaluation of Stuttering in Preschoolers

Case History: medical history, developmental history, speech and language milestones

More specific questions: when did the stuttering begin? has it changed over time? situations that make stuttering more or less severe; family dynamics; does it run in the family?

Stutter-like disfluencies vs normal disfluencies

Stutter-like:

• part-word repetition (“b-but”, “thi-thi-this”)

• single-syllable word repetition (“you you you”, “and and”)

• dysrhythmic phonation: (“mmmmy”, “cooookie”), blocks (“—toy”), broken words (“o—pen”)

Normal:

• interjection ('“um”, “uh”)

• revision/abandoned utterances (“Mom ate/Mom fixed dinner”, “I want/Hey look at that”)

• multisyllable/phrase repetition (“because, because”, “I want, I want to go”)

Counting Disfluencies

• Repetitions of sounds, syllables, or words are counted as one disfluent word

• Prolongations of sounds are counted as one disfluent word regardless of the number of iterations

• Blocks on a word are counted as one disfluent word regardless of the durations of the block

• Unnaturally long pauses are counted as one disfluent word

• Revisions are counted as one disfluent word

• In reading: the omission, modification, or addition of a word or words is counted as one disfluent word

• Fillers and starters are counted as disfluent words (um, uh, etc.)

Preschool Speech Sample

Analysis of child’s speech behaviors

• Types of disfluencies

• Frequency and duration of disfluencies

• Visible/audible secondaries

Bilingualism

Disfluencies can reach 7% when the average bilingual child is 2-4 yrs old

May be inherent to the processing involved in the production of spoken language in bilinguals

Prognosis: Risk Factors

Family History: especially if there are relatives who persisted in stuttering (less risk if family member outgrew stuttering as a child)

Sex: more males become persistent, more females recover and do so quicker

Age at onset: children who begin stuttering before age 3½ are more likely to recover

Time since onset: longer than 6 months → may be less likely to spontaneously recover

Standardized Assessments:

Stuttering is often comorbid with other S/L disorders

Articulation: GFTA-4

Language: PLS-5, TELD-4, TOLD-P

Space out testing and play to minimize fatigue in young children

The International Classification of Functioning, Disability, and Health

Severity Assessment for School-age kids & adults

Perceived by the listener

• Frequency, duration, tension of stuttering

• Includes observable secondary behaviors

Affective & Cognitive Factors Assessment for School-age kids & adults

Feelings and attitudes about stuttering and communication in general

Quality of Life Assessment for School-age kids & adults

How limiting is the disorder?

• School, employment, social relationships, self-image, etc.

Assessing severity in school-age kids & adults

Some clinical relevance because it captures what listeners experience

Provides numerical score or discrete category/level supposedly needed for insurance or educational purposes: but actually not

CAUTION: snapshot in time, observable features only, two clients can have very different stuttering patterns but same severity

Severity DOES NOT predict impact

Overall Assessment of the Speaker’s Experience of Stuttering (OASES)

Provides insights into global impact of stuttering

3 different forms

4 categories

Yields Overall Score and Impact Ratings (mild, mild-moderate, moderate, moderate-severe, severe)

3 different forms of OASES

7-12 yrs

13-17 yrs

18+ yrs

4 categories of OASES

General Information

Your Reactions to Stuttering

Communication in Daily Situations

Quality of Life

Assessing School-age Child

Similar to assessment for preschool-age children

Differences:

• Reading sample

• Negative emotions and attitudes likely to be stronger

• Can ask child, parents, teacher about school experiences

• Can talk to child directly about stuttering

Impact of Child’s Environment

Must understand how the child’s family responds to/thinks about child’s stuttering

• I.e., family support/motivation

Assessing Child’s Feelings/Attitudes

Child’s comfort level is critical

• How concerned is the child about their speech

• What does the child know about stuttering

• How does the child cope with stuttering

• How does the child feel about self as a communicator

School-Based SLP

Collect info from teachers, parents, observations in class and therapy room

May test for concomitant issues as well

IEP team meets to discuss results

• Does child’s stuttering meet state’s eligibility criteria?

• Is stuttering negatively impacting the child? (academically or socially)

CO Communication Rating Scale:

A stuttering impairment does NOT exist when…

1. Disfluencies are part of normal speech development

2. Disfluencies do not interfere with educational performance resulting in a denial of free appropriate public education (FAPE)

Treatment Recommendation

Not all kids who stutter need treatment right now

If negatively impacting child, start therapy!

Parents need to know it’s ok for child to stutter

Child’s level of concern may not match parents’ or teacher’s

If children don’t feel like they need to change, they probably won’t

Types of Stuttering Therapy

Fluency-shaping therapy

Stuttering modification therapy

Stuttering-affirming approaches

Psychotherapeutic approaches

Electronic devices

Parent-directed intervention for preschoolers

Fluency Shaping Therapy Goals

Goal: increase fluency

Focus on slower, fuller breathing from the diaphragm

Slow speaking rate by:

1. stretching phenomes

2. slowing phenome or syllable transitions

3. more frequent pausing

Reduce vocal fold tension at the beginning of words

Reduce articulatory pressure

Fluency Shaping Therapy Results

Result is slow, monotonous, but fluent speech; only used in clinic

After mastering target speech behaviors, speaking rate and prosody are increased until more natural sounding

Fluent speech is transferred to daily life outside the speech clinic

Continue to refine/practice new speech patterns until they stabilize

Fluency Shaping Techniques

Light articulatory contacts/soft starts

• Reduces tension in articulators by bringing them together gently and pulling apart slowly

Easy/gentle onsets

• Gentle onset of voicing that gradually increases in intensity

Slowing Rate

• Pausing/phrasing or slowing phonemes & syllable transitions

Stuttering Modification Therapy Goals

Modify moments of stuttering so they are less tense/briefer

Reduce fear of stuttering while eliminating avoidance behaviors associated with this fear

Assumes most school-age & adult PWS will never be normally fluent speakers, so goal is to be an effective communicator with some level of acceptable stuttering

Stuttering Modification Therapy Desensitization Causes More Control over Stuttering

Disclosing/advertising stuttering, openly talking about stuttering → Bouncing

Voluntary stuttering → Prolongation

Maintaining eye contact → Pullout

Putting self in feared situation → Cancellation

A stutter can be changed before, during, or after it occurs

4 Stages of Stuttering Modification

Identification

Desensitization

Modification

Stabilization

Stages of Stuttering Modification: Identification

Identify stuttering behaviors (core and secondary)

Feelings and beliefs

Learn how speech mechanism works

Stages of Stuttering Modification: Desensitization

Stutter openly, confront fears & avoidances

Stages of Stuttering Modification: Modification

Change how you stutter, do it more easily

Bouncing, prolonging, pull-outs, cancellations

Stages of Stuttering Modification: Stabilization

Generalize skills to the real world

Clients must becomes their own therapists and learn how to handle relapse

Electronic Devices

DAF

FAF

Masking

Rhythm

Electronic Devices to Reduce Stuttering

Changing how a PWS hears their voice usually improves fluency

May correct auditory processing underactivity

3 types of altered auditory feedback

DAF and FAF immediately reduce stuttering about 70-80% without training or therapy

Effects often diminish with time

3 types of altered auditory feedback

Delayed auditory feedback (DAF)

Frequency altered feedback (FAF)

Masked auditory feedback (MAF)

AAF outside the clinic

SpeechEasy: helps some PWS, not helpful for others

Effects tend to face with time

Treatment for Preschool-age Child Goal and Methods

Goal: eliminate stuttering, empower parents

Methods: indirect or direct therapy

Indirect Therapy

Manipulate environment & change how family interacts with child

Decrease factors that maintain/exacerbate stuttering

Increase factors that reduce stuttering

• Slower rate

• More pauses

• Fewer questions

• Simplified language

Direct Therapy

Target child’s aberrant speech behaviors, rather than environmental factors

Child alters the way in which he/she speaks

Usually conducted within clinic room by SLP, but parents can also deliver treatment

Effectiveness of Stuttering Intervention

Early diagnosis and treatment is best practice

Full recovery in school-aged children is unlikely

Stuttering decreases 60-80% regardless of therapy used

What is Cluttering?

Perceptually rapid, irregular speech with many disfluencies that is difficult to understand

Disfluencies are typically incomplete phrases, revisions, fillers (usually without tension)

Misarticulations: collapsing or distorting words

Disorganized language

Often poor self-monitoring/awareness

Cluttering vs. Stuttering

Stuttering is primarily a motor speech disorder with a linguistic component

Cluttering sits at the convergence of language formulation and articulatory control

PWC: disorganized, confused, and reiterative speech patterns not seen in PWS

Cluttering vs. Stuttering Table:

Cluttering Facts

Average age of diagnosis is ~8 yrs; language has become complex and lengthy

Common Disorders Co-occurring with Cluttering

Stuttering: 14-32% of PWS show cluttering symptoms

Articulation disorders: different from the cluttering symptoms of omitting phonemes or syllables due to rapid speech rate

ADHS: propensity to hurry, do things quickly

Learning disabilities: likely related to language deficits seen in the speech and writing of PWC

Autism: more research in this area recently

Voice Disorders

Difficultly initiating, maintaining, or controlling voice

Vocal folds don’t vibrate normally

Characteristics of Voice Disorder

Pitch (Frequency): too high, too low

Loudness (Amplitude): too loud, too soft

Voice Quality (Timbre, Complexity): hoarse, breathy, strained

Resonance (how vocal tract modifies sound): hyper/hyponasal, throaty

Classification of Voice Disorders

Functional

Organic

Neurological

Functional Classification

No changes in laryngeal structure

Can be stress or anxiety related (or psychogenic)

Habitual or maladaptive behavior: using your voice wrong

Organic Classification

Structural cause

Laryngeal web, tumors, swelling, etc.

Neurological Classification

Neurological cause

E.g., vocal fold paralysis resulting from conditions affecting the nervous system

Vocal Pathologies

I. Trauma

Behavioral

Mechanical

Chemical/Thermal

Mechanical Trauma from Intubation

Result = Granuloma/Contact Ulcers

Examples of Behavioral Trauma

Speaking during menstrual cycle

Aspirin (drugs)

Intense personality

Vocal Pathologies

II. Unknown Causes

Ventricular Dysphonia: false vocal folds interfere during phonation

Stress/anxiety: can cause Muscle Tension Dysphonia (abnormal muscle activity with unknown cause)

• Excessive use/misuse of voice, GERD, learned behaviors after upper respiratory illness

Puberphonia (mutational falsetto)

Vocal Pathologies

III. Masses on the vocal folds

Any mass or lesion along the vocal fold edge can cause glottic closure and cause voice abnormalities

Tumors, polyps, nodules, papilloma, ulcers

Diagnosed by medical team

Will impair voice variably according to location, size, and firmness

• Increased bulk

• Altered vf shape and tension

• Limited vf mobility

• Not enough approximation

• Compensatory excessive tightness of approximation

Vocal Fold Nodules

Excessive voice use causes swelling, which may result in tissue changes if voice is not rested

Small, callous, sessile, bilateral protuberances on the inner surface of the vocal folds

Can be acute or chronic

Polyps

Benign growth

• Acute, focal misuse

Soft, fluid filled sacs

Usually one-sided

May be sessile (closely-attached) or pedunculated (attached by a stalk)

Interfered with VF contact during vibration resulting in breathy voice quality

Differentiate Nodules from Polyps

Location:

• P & N: midpoint or anterior

Uni/Bilateral:

• P: usually unilateral ; N: usually bilateral

Definition

• P: soft blister ; N: callous

Causes

• P: acute focal misuse ; N: chronic abuse

Symptoms

• P & N: pretty similar

What are Contact Ulcer Granuloma

Inflamed lesions, usually in posterior regions

• Sores on mucous membrane of arytenoid(s)

• Can be painful

Contact Ulcer Granuloma Causes

• Usually GERD

• Forceful closure of cartilaginous portion of vocal folds

• Intubation trauma

Papilloma

Benign, viral neoplasm/tumor

Stippled mass, like a wart

Caused by exposure to HPV

Juvenile or adult papilloma

May occur in the pharynx, trachea and larynx

Benign, but may be precancerous

Carcinoma

Malignant tumor

Life-threatening

Smoking is a major cause of laryngeal cancer

• Risk increases substantially when alcohol is combined with smoking

Voice changes may be an early detection of disease

Edema

Reinke’s edema: swelling (fluid fills the superficial layer of the lamina propria

Translucent, sac-like

Smoking, reflux, chronic vocal abuse

Laryngeal Web

Membrane

Congenital or scar tissue from trauma

Consequences:

• Stridor

• Hoarseness

• Aphonia

Cysts

Glandular duct blockage (glob of fat or fluid-filled growth), contained within membrane

Vocal Pathologies

IV. Neurogenic Voice Disorders

Disruption in structure or function at CNS or PNS level

Dysfunction of Vagus Nerve (Cranial Nerve X)

Neurological Diseases

Parkinson’s disease

ALS

MS

Spasmodic Dysphonia

Disorder affecting motor control of the larynx

Hallmark symptom: Intermittent voice stoppage

Strained voice, pitch breaks, worsens with stress

Thought to be psychogenic at one point: now considered a form of focal dystonia

• Involuntary muscular contractions and abnormal postures

Adductor, Abductor, Mixed

Vocal Fold Paralysis

Unilateral, bilateral, adduction, abduction

Bilateral abductor vocal fold paralysis if life threatening and requires prompt management

Normal phonation but may progress to complete respiratory obstruction

Caused by thyroidectomy, neurological disorder (PD, CVA, MS), congenital, etc.

Medialization Thyroplasty

Place implant through thyroid behind vocal fold, fat injections can also be used

Laryngectomy

May only need chemotherapy if caught early on or simpler surgery

• Cordectomy

• Hemi laryngectomy

Larynx may need to be removed completely if not caught early

Speech After Laryngectomy

Mechanical

• Artificial larynx

Surgical

• TEP (Tracheo-Esophageal Puncture)

  • Most frequently used method of alaryngeal speech

Other

• Esophageal Speech: air is injected into upper esophagus and released in a controlled manner to create sound source for speech

TEP

Tracheoesophageal puncture

• One way valve allowing exhaled air to pass into pharynx. This airstream vibrates the mucosa of the upper PE segment

• Similar physiologic principles of normal speech

  • Efficient air flow source

  • Natural phrasing and varied voice efforts

• When the air source subsides, the valve closes and prevents aspiration of secretions