6A: Fluency Disorders

Fluency

• Effortless flow of speech

• Ability to produce speech

  • with normally long strings of sounds,

  • at a normally rapid rate,

  • without pausing or hesitation, and

  • with a normal amount of effort

Disfluency

• Disruption or breakdown in flow of speech

Normal disfluency

• Everyone experiences minor interruptions in flow of speech at times

  • Especially common in young children as they are starting to produce sentences

• How do we distinguish “normal” disfluencies from stuttering?

What is stuttering?

• An interruption in the flow of speaking characterized by specific types of disfluencies, including:

  • repetitions of sounds, syllables, and words (e.g., “Look at the b-b-baby,” “Let’s go out-out-out”)

  • prolongations of consonants when it isn’t for emphasis (e.g., “Ssssssssometimes we stay home”)

  • blocks (i.e., inaudible or silent fixation or inability to initiate sounds)

Normal Disfluency vs possible stuttering

Possible Stuttering

• Repetitions

  • syllables

  • individual sounds

• Sound prolongations

• Sound blocks

• Tense pauses

• Bursts of speech

• Clusters of disfluency

• Associated body movements

Distinguishing Normal Disfluency from Possible Stuttering

• In the first 6 months after onset, groups can look very similar

• Strong decline in disfluencies within 1st year in normal disfluency group

• More likely to be stuttering if there is a family history of stuttering

• strong genetic component to stuttering

Types of fluency disorders

1. Developmental stuttering

2. Non-developmental stuttering

3. Cluttering

Developmental Stuttering: Facts (concepts not numbers)

• vast majority of people with fluency disorders

• About 1% of the population currently stutter

• About 3% of children will stutter during course of development

  • About 75% of children recover without any formal treatment

• More prevalent in boys (3:1)

• Typical onset between 2–5 years of age

Developmental Stuttering is…

Heritable

• More often in twins and runs in families

• Suggests genetic predisposition

Developmental stuttering is…

Variable

• within utterances

• day-to-day

• across situations

Variability…

Decreases:

• novel speaking manner (e.g., singing)

• while alone, speaking to animals or kids

• disruptions in auditory feedback (hearing aid that will play your speech back to you in a delayed form)

Increases:

• anticipating stuttering (e.g., waiting to respond)

• having to say specific words (e.g., your name, a joke)

• talking on the phone

Overt/ Primary Characteristics

1. Part-word repetition

   • “mi-milk”, “d-d-d-dog”

2. Single syllable word repetition

   • ”I…I want that”

3. Multi-syllabic word repetition

   • “Lassie…Lassie is a good dog”

4. Prolongation

   • “I’m Tiiiiiimy Thompson”

Overt/ Primary Characteristics cont.

5. Silent/tense pause (block)

   • “Can I have some….milk?”

6. Phrase repetition

   • “I want a…I want a ice cream cone”

7. Interjection

   • “He went to the …uh…circus”

8. Revision or incomplete phrase

   • “I lost my…Where’s Mommy going?”

Covert/ Secondary behaviours

Bodily Movements/Struggle

• Facial grimaces

  • e.g., blinking eyes, wrinkling forehead, distorting mouth, tongue protrusion

• Head movements

  • e.g., looking away, jerking

• Loss of eye contact

• Body movements

  • e.g., limb movement, foot tapping

*Unconscious way of trying to avoid stuttering

Covert/ Secondary behaviours cont.

Psychosocial behaviours

• Avoidance

  • e.g., fillers, pretending to think, avoiding situations and people, appearing shy and quiet

• Emotional responses before speaking

  • e.g., fear of loss of speech control

• Emotional responses after stuttering

  • e.g., embarrassment, shame, anger, frustration

Non-developmental stuttering is either:

Sudden onset of stuttering in previously fluent adult…

1. Neurogenic

   • Linked to identifiable neurological event

2. Psychogenic

   • In context of psychological disturbance

Neurogenic

Etiology

• Neurological damage or disease

  • e.g., stroke, head injury, neurosurgery, MS, Parkinson’s disease, meningitis

• Exposure to toxins

  • e.g., drugs, poisons

  Distinctions from stuttering

  • Equally disfluent across different speaking situations

  • Secondary behaviours less common

  • Negative emotional response less common

Psychogenic stuttering

Etiology

• e.g., psychological trauma, anxiety, depression, other psychological disorder

Distinctions from neurogenic stuttering

• May be intermittent

• Unusual or bizarre speech/language patterns

• May respond quickly to behavioural treatment

Cluttering

• Fluency disorder of unknown origin characterized by sporadically excessive rate, and incomplete and distorted articulation

• Speech characterized by rapid rate, disfluencies, and articulation errors, often accompanied by spoken and written language difficulties. These signs usually occur without the speaker’s awareness or concern

• Rare

Cluttering characteristics

• Frequent whole word and phrase repetitions

• Rapid rate of speech

• Irregular rate of speech

• Misarticulations

  • Slurred or deleted phonemes

  • Substitutions

Distinctions from stuttering

• Part-word (sound or syllable) repetitions are infrequent

• Secondary behaviours (e.g., tension, struggle, avoidance) not usually present

• Lack of awareness of or negative emotional response to the problem

• Often more fluent in conditions where person who stutters is less fluent

  • e.g., under stress, with authority figures, when paying attention to their own speech, when wanting to be fluent

Cluttering vs stuttering

Cluttering:

• much faster speech rate

• unaware of disfluent speech (no anxiety)

• Disorganized

Stuttering Theories

• Demands & capacities theory

  • Intrinsic & extrinsic social demands exceed the child’s capacities for fluent speech

• Covert repair theory

  • Children have a disordered phonological system

• Neuropsycholinguistic

  • Stuttering = disruption in timing of linguistic formulation & speech movement

Likely Causes…

Likely a combination of factors –

• genetic predisposition

• neurological dysfunction

  • atypical cerebral organization (over-activation in right hemisphere; under-activation in left)

  • difficulty with auditory feedback

• Environmental stressors

Assessment: Are speech disfluencies present?

• Speech sample

• Disfluency count (% syllables stuttered)

• Normal disfluency count is below 3%, higher than 3% is cause for concern

• Type:

  • mild: easy repetitions

  • more severe: sound blocks, sound prolongations; body movements

Assessment: What is the nature of the speech disfluencies?

• Occurrence of within-word disfluencies

• Stuttering severity scales

• Occurrence of secondary behaviors

• Speaking rate

Examples from communication attitude checklist and stuttering attitudes checklist

*Concepts not specifics

• People worry about the way I talk

• I don’t talk like other children

• Some kids make fun of the way I talk

• I let others talk for me

• I sometimes feel that my stuttering is my own fault

• My teachers should not make me answer questions in class if they think I will stutter when I answer

• I feel that it is best if I do not talk about my stuttering with my friends

• My stuttering is my biggest problem

• Sometimes I feel I should be able to stop my stuttering without help

• I think stuttering makes it harder for me to make friends

• My stuttering has caused me to make poorer grades in school

• Sometimes I think my parents may have caused my stuttering

• I doubt if speech therapy can help me a whole lot

Treatment for early stuttering:

• Uses indirect methods

  • changes in environment to stabilize fluency

  • reinforcing fluent speech

  • *family involvement

    • deal with anxiety

  • e.g., Lidcombe program

Lidcombe program

• Clinician-mediated

• Parent-implemented

• Behavioural treatment

  • preschoolers

  • adapted for school age (mild-moderate stuttering)

• Goal: no stuttering

• Several outcome studies

  • 92% achieve and maintain near zero stuttering up to 7 years post treatment

Treatment for stuttering

1. Fluency shaping

2. Stuttering modification

• Both use behaviour modification to reduce speech disfluencies

• May be used in isolation or in combination

Fluency shaping

• Designed to modify all aspects of client’s speaking behavior Robb, 2014

• Behavioural modification

  • “relearning” speech motor movements to produce fluent speech

• Goal = stutter-free speech

Fluency Shaping: learn new pattern of speaking

a. Speak at reduced rate

b. Prolong vowel portions of words

c. Use slow and smooth onsets of words

d. Continuous phonation

Fluency shaping

• Potential for rapid, dramatic change

• Some problems with Fluency Shaping

  • Abnormal/artificial speaking pattern

  • Skills may not easily transfer out of therapy context

  • Attention to speaking pattern ongoing

Stuttering Modification

• Designed to address individual moments of stuttering, as opposed to changing entire pattern of speaking behaviour

• Clients learn to

  1. stutter more fluently, with less tension

  2. use light articulatory contacts during speaking

  3. reduce situational fears and negative associations with stuttering, feel in control of stuttering

Problems with stuttering modification

• Slower observable change

• May still have moments of stuttering

Nontraditional treatment approaches

• Hypnotherapy

  • Controversial

  • Not a ton of evidence to prove this works

• Drug Therapy

  • Some success with dopamine blockers

  • focus on anxieties associated with stutters

• Electronic Devices

  • Closely resemble hearing aids

  • Delayed auditory feedback

Cultural considerations

• Careful consideration required in the assessment and treatment of fluency disorders among individuals from diverse cultural backgrounds

• Use of fluency shaping versus stuttering modification therapy needs to be considered from a cultural perspective

• Special considerations for multilingual speakers

  • Likely to stutter in multiple languages, but more in the less proficient language

  • Research is needed to support assessment and treatment in this population

How listeners can help

• Listen to what the person is saying, not how they are saying it

  • Maintain natural eye contact

  • Wait until the person is finished (do NOT finish sentences or fill in words)

  • Be especially patient on the telephone

• Don’t give advice (e.g., slow down, take a breath)

  • You speak in a slow & relaxed way (modelling).