COMD 5500 Fluency Gomez , COMD 5500

What is communication apprehension?

Defined as the fear or anxiety associated with either real or anticipated communication with another person or persons.

- 20% of the general pop contends with CA.

Context-Based CA

having fear or anxiety about communication in one context while having no issues in others.

Audience-Based CA

Having fear or anxiety about talking to a particular individual or group of individuals while having no issues with other individuals.

Situational CA

Having fear or anxiety about talking to a particular individual or group of individuals in a particular situation.

Traitlike communication apprehension

- a genetic predisposition for feeling anxious in most situations

- Change can be accomplished but its typically with long-term treatment effort.

- On a continuum, some with high levels of CA are literally "scared speechless"

- Scared and anxious in virtually all communication situations.

What can cause CA?

- Childhood reinforcement patterns experienced during preschool development + expectancy learning (we seek to learn what outcomes are likely to occur as a function of our behaviors).

- SO if our communication is positively reinforced we will want to communicate more. If we are punished or given inconsistent reinforcement or punishment when we communicate, we will want to talk less.

Treating Communication Apprehension

1. Communication Skills Training: help individuals with CA build confidence & reduce apprehension

2. CBT - addressing negative thought patterns & replacing them with more positive, constructive thoughts.

3. Exposure therapy - gradual exposure to communication sit, can desensitize them.

4. Create a Supportive Environment

5. Systematic Desensitization: visualizing situations that would cause CA and learning to relax your body as you experience them (unless trained refer out)

6. Visualization: have the person create a pic in their mind of a successful outcome in a feared speaking situation.

What is the diagnosogenic theory of stuttering?

-The idea that the diagnosis of stuttering causes stuttering (e.g. negative parental reaction to normal developmental disfluency)

-The child has moved from normal to abnormal speech patterns which over time emerge as stuttering.

- This is one of the biggest reason you'll hear for not mentioning or even treating stuttering early on.

What is the anticipatory struggle hypothesis for stuttering?

- Theorized that stuttering arises b/c children become convinced that speech is difficult but must be done well. The results of these beliefs are tension and struggle when attempting to execute perfectly fluent speech movements.

What is approach-avoidance conflict for stuttering?

- Stuttering as a struggle for individuals with desires to both speak and not speak which leads to ill-timed starts and stops that are manifested as disfluencies.

State vs Trait Confidence

State: confidence that is situation specific

Trait: confidence that is born of an inherent believe in one's ability to succeed, not situational.

Why are the stuttering theories wrong?

- The disfluencies of CWS are qualitatively different from their non-stuttering peers, they present significantly more part-word repetitions, prolongations, and hesitations. They are NOT normally speaking individuals.

- Attempts to eliminate stuttering via emotional counseling have not been particularly effective.

- Direct therapy methods are reported effective with many preschool clients. Such success counters the belief that there is harm in calling attention to stuttering.

Educating students/clients

- Educate clients: what is stuttering? What is good communication? Expose them to famous and successful PWS

-Understanding one's own stuttering sets the stage for acceptance. Clients need to become comfortable with stuttering so that change can occur.

- Fear of communication MUST BE DIMINISHED for any real improvement to take place.

Secondary Behaviors

Typically require more focused treatment than merely open or voluntary stuttering b/c they have become habits.

Easier to treat than disfluencies.

Typically when on behavior is focused upon, other associated behaviors are not addressed until later.

Make the client aware through mirror work. REMEMBER stuttering is ok, we just want to help our clients do it in the least struggled way. It can be communicated that secondary behaviors are not helpful

Building Resilience

Planned interruptions, giving unequal amounts of cards, stickers, etc,. Practicing verbal comebacks.

What are the goals of stuttering modification?

1. Stuttering in a way you can manage

2. Talking without tricks or avoidance

3. Taking charge of the stuttering rather than letting it continue to run your life.

Stuttering Modification Techniques

Cancellations

Pull-outs

Preparatory sets

fluency shaping techniques

Performed with the idea of changing the rate and rhythm of one's speech overall to gain fluency.

changing the way you speak all the time rhythmically so you can slow down essentially and increase the ease with which you speak. You need to change FUNDAMENTALLY how you talk, and it could also mean talking very slowly.

Fluency shaping techniques

Slow Down Speech Rate

Pausing & Planning: breaking large speaking tasks into manageable chunks

Easy Onsets/Gentle Initiation: Starting a word gently with a soft initiation of the vocal cords and oral musculature. Teach relaxation tech and controlled breathing. Can use "h" in the beginning.

Light Articulatory Contact: Using gentle soft contacts can reduce tension and help smooth speech flow.

Continuous Phonation: Constant phonation involves maintaining a continuous vibration of the vocal cords during speech.

Prolongations: stretching out sounds to create smoother speech and reduce blocks.

Generalization of Techniques

- Transfer activities in the therapy room: bringing in people (changing the audience)

- Telephone Calls

- Transfer Activities outside the therapy room

- Role Play

Avoidance reduction & desensitization

• Voluntary Stuttering

• Open Stuttering

• Cognitive Behavioral Tx

• Advertising or Self Disclosure

• Progressive Exposure

• Role Playing & Rehearsal

Direct treatment

- The point of direct therapy is to shape fluent speech via teaching, reinforcement, and other feedback to the child.

- Many of the same elements will be in place from indirect Tx such as the parents doing their best to provide a relaxed communication environment. (YOU CAN ALWAYS DO THIS)

- Unlike indirect therapy, the parents may "reward" fluent speech overtly.

- Depending on your ideology, "easy speech" can be reinforced over "fluent speech". The idea is to NOT send the message that stuttering is bad, thereby making the child think that his or her usual speech is unacceptable.

Indirect treatment

Counseling caregivers is indirect therapy.

Typically includes modeling and environmental changes for the CWS made by the parent(s)

Other disorders of fluency

Neurogenic Disfluency: Acquired stuttering resulting from a neurological insult of some sort

Cluttering: Marked by expressive language deficits

Psychogenic Disfluency: Sudden onset in response to a significant event

Palilalia: Associated with basil ganglia dysfunction, causes involuntary tics and repetitions

Assessment - Frequency

3 words per 100 words as the "rule of thumb"

A 300-syllable sample is recommended

Stuttering Modification

Taking care of stuttering in that moment, regardless if it's before, during, or after. These are good for identification and eliminating or lessening the tension associated with stuttering.

What should go first? Secondary behaviors or stuttering modifications?

It is recommended to target first the secondary behaviors and follow up with stuttering modifications.

Pull outs

STUTTERING MODIFICATION

- Also called easing out or sliding out

- Identify the tension, reduce that tension in the moment, then continue and finish the word.

1. The moment of stuttering occurs

2. Find the tension during the moment of stuttering

3. Pull out of the "hard" stuttering event with less tension

Cancellation

STUTTERING MODIFICATION

- after the moment of stuttering to reduce that tension

1. Complete the block

2. Pause for 3 seconds

3. Calm down

4. Pantomime the block silently

5. Pantomime it the way you intend for it to happen

6. Say it again in a modified/easier fashion

Preparatory Sets

STUTTERING MODIFICATION

-Taking time to prepare for the word that you know you will stutter on so that you can consciously relax all the areas that you know are going to get tense.

1. Pause before the word that will be stuttered (prepare)

2. Relax the throat and mouth muscles

3. Recall the way in which the word is normally stuttered ("rehearse" the tension that is normally associated with it)

4. Plan the modification needed to make the stuttering moment less struggled.

5. Keep the sound flowing forward.

Cancellations vs Pull outs

Using cancellations the client learns that struggle is not necessary and can be counterproductive toward learning more controlled speech. It is exploratory in nature. Occasionally the client will forget or be unable to produce a preparatory set. In these instances one should work to shape the hard stutter into an easy one using pull outs.

What needs to be diminished for any real improvement to take place?

Fear of communicating

Self Advocacy

- Giving a class/work presentation about stuttering

- Encouraging a client to disclose (advertise) their stuttering when they feel comfortable.

- Anything that creates agency (i.e., ability to act independently)

Laying a foundation for success with techniques

- PWS should become desensitized to feared words and situations and the sound and feel of their own stuttering.

- Should the speaker remain self-conscious about speech, these changes will be difficult to make.

- Techniques should be presented as OPTIONS to our clients.

Caution about fluency shaping

- The client needs to know first that stuttering is not bad.

- Many clients are uncomfortable with the controls that are necessary to speak fluently. These clients report that the resulting speech is limiting & requires too much concentration.

- In order to decrease avoidance behaviors, the client must be open about what he/she is avoiding. One cannot confront what is hidden.

Pausing & Planning or Phrasing

FLUENCY SHAPING

-Break a large speaking task down into manageable chunks.

-Reported to be a preferred approach because the cognitive demand is lower.

Easy Onsets

FLUENCY SHAPING

- Involve starting a word gently with a soft initiation of the vocal cords and oral musculature

- Teach relaxation techniques and controlled breathing.

- Demonstrate easy onsets by producing words and sentences with a gentle, relaxed beginning. Can include using a lower volume of voice or adding an "H" sound to get a more relaxed sound.

Light Articulatory Contacts

FLUENCY SHAPING

- Using gentle, soft contacts can reduce tension and help smooth speech flow.

- Help bring awareness to the amount of pressure or tension your client uses when speaking.

Continuous Phonation

FLUENCY SHAPING

- Involves maintaining a continuous vibration of the vocal cords during speech, helps create smoother transitions b/w sounds and words.

- Emphasize the lack of breaks or abrupt starts and stops.

-Focuses on diaphragmatic breathing. Encourage deep, relaxed breaths that support sustained vocalization.

Prolongations

FLUENCY SHAPING

- Stretching out sounds can help create smoother speech and reduce the likelihood of stuttering blocks. Emphasize that prolongations involve extending the initial sound of a word in a relaxed manner.

What is cluttering?

- The verbal manifestation of Central Language Imbalance

- Disturbances in perception, articulation, and formulation of speech and often by excessive speed of delivery

Common Symptoms of Cluttering

1. Excessive speech

2. Jerky rate and short respiratory span

3. False starts, breaks, irregular pauses

4. Omission of syllables - "collapsing words"

5. Polysyllabic words - "computer - co uter"

6. Poor organization of language - "mazes"

7. Difficulty self-monitoring

8. Many disfluencies

9. Word finding

10. Poor articulation

11. Disorganized thinking

Coexisting disorders of stuttering:

"Central Language Imbalance"

-Difficulty with organizing what to say (a language

formulation task)

-Not noticing/not reacting to listener cues (highly

unaware)

-Lack of awareness regarding fast, choppy speech

(with concomitant articulation errors)

-Coexistence of reading/writing difficulties Coexistence of ADHD/ADD w/cluttering?

Pure cluttering is rare T/F

True - Usually it coexists with other disorders

People who stutter are AWARE of their disorder, helping them to build awareness can help them see the benefit of treatment T/F

False - they are UNAWARE of their disorder

Cluttering treatment includes:

- slow rate

- syllabization

- reading aloud

- exaggerated accentuation

- reduce disfluencies

- increase language coherence by planning a narrative

Define State Confidence

Confidence that is situation specific. (i.e. fluency being part of the state of confidence and vice versa)

Define Trait Confidence

Confidence that is born of an inherent belief in one's ability to succeed- not situational.

Reasons for adult recovery

1. practice and eventual habituation of speech modifications

2. motiviation to change

3. improved maturity

4. increased confidence

5. greater awareness of problems

6. relaxation

7. change in attitude

8. making a conscious decision to change

Define anticipatory struggle hypothesis

(Bloodstein 1958) theorized that stuttering arises because children become convinced that speech is difficult but must be done well. The results of these beliefs are tension and struggle when attempting to execute perfectly fluent speech movements.

Define approach-avoidance conflict

(Sheehan 1958) wrote of stuttering as a struggle for individuals with desires to both speak and not speak which leads to ill-timed starts and stops that are manifested as disfluencies.

Define diagnosogenic theory

(Johnson, 1942) The idea that diagnosis of stuttering causes it. It occurs when a child's normal speech breakdowns are mislabeled (by parents) as stuttering and, consequently, the child is instructed to change how he or she talks. The child has moved from normal to abnormal speech patterns, which over time emerge as stuttering.

This is one of

the biggest reason you'll hear for not mentioning or even treating stuttering early on.

Core behaviors of stuttering

repetitions, prolongations, blocks

The core behaviors (disfluencies) happen 10 times more often in CWS vs. children who do not T/F

True

The breakdowns in children who do NOT stutter usually consist of:

-Interjections ("um", "ah", "you know", "like")

Revisions (Let's... we are all going)

Repetitions are usually 1-2 iterations

VS CWS

• Repetitions usually happen 2-5 times in CWS

• Additionally, the iterations are usually produced more quickly

Stuttering disfluencies (core behaviors) make up ________% of the breakdowns in CWS

75

Less common traits

WORD REPETITIONS & PHRASE REPETITIONS

Stuttering trends

- adaptation

- consistency

- word weights (consonants, content words, longer words, early words, less frequent words)

- feeling a loss of control

Subgroups in stuttering classified as

- CWS+ (those CWS who have other language/speech deficits

- family history

- type

- severity

Fluency enhancing conditions

- Speaking under masking noise

- Singing

- Talking to animals and infants- why might this be?

- Choral reading example below

Why do fluency enhancing conditions work?

- Increase in phonatory duration (i.e., Constant Phonation Tx)?

•Shift to use of the right hemisphere?

•Decrease Rate?

•Rhythm change?

THE STUTTERER STEREOTYPE

• Quiet

• Shy

• Passive

• Nervous

• Withdrawn

• etc.

How sterotypes are maintained

- confirmation bias

- self-fulfilling prophecy

Onset of stuttering:

-Usually begins before 3 (pre-school years)

•Develops gradually over weeks

•Can arrive suddenly

•Distressing events (divorce of parents or abuse) close to the onset could be responsible for

abrupt occurrences (unsubstantiated)

Onset of stuttering: MYTHS

Overanxious parents worries about normal

speech breakdowns.

•In Dr. William's experience parents are actually good at discerning normal vs abnormal stuttering/speech

Stuttering (as defined) is not considered part of normal development T/F

True

•Spontaneous recovery is inconsistent and not a "phenomenon on which to base a guarantee" T/F

True

Spontaneous recovery happens:

4/5 (75%)

Incidence

(those that have ever stuttered at some point in their lives) is 5%

Prevalence

The PREVALENCE (those that stutter at a given point in time) is 1%

Common Avoidance Behaviors

-"word substitutions (e.g., "Beggars can't be,

well...pickers")

• rephrasing utterances ("I need to go shopping for...let's go to the mall"),

• interjections ("My name is um, ah, um, you know..."),

• answering with "I don't know,"

• describing a concept rather than using a feared word- (i.e., saying "2") ("It wasn't 1, but I don't think it

was 3 either"), and

• purposely mispronouncing words to dodge a problem sound."

Extreme avoidance behaviors

• "Ordering food based not on what one wants to eat, but

on how easy it is to say

• Giving oneself a nickname

• Pretending to be sick (e.g., because it's book report day)

• Feigning an accent

• Avoiding speech altogether

Secondary behaviors

eye blinks

throat clearing

foot taps

pitch change

easy words, sounds, or phrases to help launch the difficult ones.

Covert Stuttering

Covert stuttering includes tying to hide the anticipation, stress, fear, guilt, shame, and denial (Douglass & Quarrington, 1952; Hood & Roach, 2001)."

Emotional impact can be tremendous

Teasing and bullying

9/10 of grade-school CSW experienced bullying

Adolescents who stutter are almost 3 times as likely to be bullied as are teens in general"

Dealing with teasing and bullying

(1) AVOID BULLY or STAY IN GROUPS

(2) IGNORE

(3) CONFRONT

(4) HUMOR

(5) EDUCATION

(6) SEEKING HELP

Other disorders of fluency

- Neurogenic disfluency

- cluttering

- disfluencies w/ ID

- psychogenic disfluency

- palilalia

Stuttering frequency

3/100 "rule of thumb"

Stuttering speech sample

• A 300-syllable sample is recommended to find fluency data such as frequency, type, duration, word position, and secondary behaviors

Other aspects of speech sample:

Additionally, evaluating other aspects of communication such as voice, resonance, speaking rate, intelligibility, and non-stuttering disfluencies (interjections, fillers, etc.)

Additional information during assessment

- case history

- attitudes

- consistency

- determining situational stuttering factors

phonological or expressive/receptive language