Speech Disorders Exam 1

What anatomical processes are affected by stuttered speech?

- respiration: interrupted breathing/block

- phonation: locked vocal folds (adducted/abducted)

- articulation: tongue/lips get stuck

- hearing: delayed auditory feedback (delay between what you say and what you hear) has shown improvements in stuttering

- neurological;vascular: ex, increased blood pressure & impact on neurological processes

What are some considerations when defining stuttering?

- diagnostics

- intervention

- insurance companies

What are non-observable aspects of stuttering?

what resides below the surface (e.g., fear, shame, guilt, anxiety, hopelessness, isolation, denial, etc.)

To address stuttering, what are two interrelated issues to account for?

1. person (psyche) - non observable

2. behavior (what you see)- observable

According to Wingate (1964), the ideal definition of stuttering should include what 3 components?

- identify and emphasize on speech and language features

- be totally dependable on observable facts

- make no mention of causation

What is the prevalence of stuttering?

1% of the population at any one time

-> higher in some populations, e.g., down syndrome (20+%)

-> ex: study of people who stutter in Worcester today

What is the incidence of stuttering?

5% of the population who stuttered at any time

-> how many people have stuttered in their lifetime

True or false: prevalence will always be greater than incidence

False, incidence will always be greater than prevalence because it considers history

What is bi-directional communication? What impact does this have on stuttering?

- Bi directional communication: talking with someone of a relatively equal linguistic ability

- stuttering usually occurs in bi directional communication

What is the child onset age range?

2-7 years old

Is stuttering random?

No, it's not random (e.g., it occurs in longer more complex utterances)

Can stuttering change over the course of hours or days? In other words, does it change in different situations?

Yes, it can. Think of a PWS going through a new, dramatic change such as starting a new school.

What is the difference between adults and children who stutter when going through a dramatic change?

preschool age kids don't experience dramatic changes like older kids and adults would.

What does it mean when stuttering tends to wax and wane over long periods of time? What age group is this typically seen in

wax: worsen

wane: better

-> typically seen in children, sometimes adults

What gender is stuttering more common in? What's the ratio and how does that ratio change over time?

- Stuttering is more common in males

Ratio- male to female 4:1

-> This ratio is closer at the time of onset, but young girls evolve out of it easier (stronger language skills)

Is stuttering genetic?

Yes, stuttering tends to run in families

What is the percentage of PWS spontaneous recovery? What does spontaneous recovery mean?

- 80% aka 4/5 kids who stutter

- Spontaneous recovery: recovery from stuttering without any kind of intervention

What percentage of kids go through stuttering when they're young?

20%

On average do PWS have different personality traits, intelligence, or psychological makeups compared to PWNS?

No, on average PWS are no different from PWNS in any/all of these things, but that doesn't mean that a PWS wont have a psychological problem, etc.

What is the difference between state and trait anxiety?

State anxiety: anxiety from something in the moment

-> ex: anxious due to presentation

Trait anxiety: always anxious

According to research, how many PWS have pathological levels of anxiety (aka, trait anxiety)

as many as 50%

What is the most common 'problem' for children who stutter?

articulation and phonology, but there may be others

About what percent of CWS also have a speech sound disorder?

30-40% (over 1/3)

are CWS voice problems any different than PWNS

No, there is no difference than PWNS

Do parents of CWS treat their children differently than parents of CWNS? Do parents cause stuttering?

No and no according to research that has been conducted

true/false: temperament is inconsistent and environment doesn't have an impact on temperament

False, temperament is consistent but environment has an impact on temperament (think of temperament on a continuum)

What is the difference between behaviorally-inhibited and behaviorally expressive temperaments

ex of behaviorally inhibited- shy child

ex of behaviorally expressive- energetic child

According to studies, CWS & PWS in general have what kind of temperament? How does this impact their behaviors?

- C/PWS are more sensitive than C/PWNS

-> sensitive: people who are acutely aware of mistakes

- They may be more likely to react to their primary (SLD) behaviors to develop secondary ones

What are stutter-like disfluencies?

also called "within-word disfluencies;" primary or core behaviors -> atypical

- sound/syllable repetition

- whole word repetition (mono-syllabic)

- audible & inaudible sound prolongation

- broken word

What are non-stutter-like disfluencies

also called "between-word disfluencies," "non-stuttered speech," or "normal" -> typical

- phrase repetition

- revisions

- interjections

- multisyllabic WWR

SLD: give an example of SSR

-> va-va-va-vacuum

-> l-l-l-lamp

SLD: give example of WWR

-> I-I-I

-> She-She-She

SLD: give example of audible sound prolongation

aaaaaaaapple

SLD: give example of inaudible sound prolongation

#apple

What happens to the articulators during sound prolongations?

articulators get stuck

SLD: give an example of broken word

aaaa#pple

What is the threshold of SLD's for PWS?

3/4%+ in speech (frequency issue)

NSLD: give an example of phrase repetition

he went- he went to the store

NSLD: give an example of revisions

she went- he went to the store

NSLD: give an example of interjections

he- um- went to the store

NSLD: give an example of multisyllabic WWR

he was going-going to the store

Is severity related to age? How many CWS start severe?

no, 1/3 of kids start severe

how do we classify the different levels of stuttering severity?

mild, moderate, severe (ex: 3% mild; 10% severe)

how does guitar classify the different levels of stuttering severity?

normal, borderline, beginning, intermediate, advanced (advanced = adults)

how does initial severity typically progress?

switch from primarily SSR's to more prolongations as severity increases

-> usually begins with no stress as kids aren't aware they're stuttering - produce brief and effortless SSR's and WWR's.

-> as they get older they become more aware and begin to react or stop them. As a result they start to struggle which turns into more prolongations and broken words

How many CWS start off with brief and effortless SSR's and WWR's

2/3 of CWS start like this

What is the cause of child onset, neurogenic, and psychogenic stuttering?

child onset: no specific cause

neurogenic: neurological injury

psychogenic: conversion reaction (experience something traumatic causing an impact on speech mechanisms)

Where is the location of disfluencies in child onset, neurogenic, and psychogenic stuttering?

child onset: initial part of sentence

neurogenic: initial, medial & final positions (throughout sentence)

psychogenic: usually initial or stressed syllable

Does child onset, neurogenic, and psychogenic stuttering have struggle/secondary behaviors?

child onset: yes

neurogenic: no

psychogenic: no

Does child onset, neurogenic, and psychogenic stuttering have anxiety/concern?

child onset: yes

neurogenic: no

psychogenic: no

Does child onset, neurogenic, and psychogenic stuttering have a genetic history of stuttering?

child onset: yes

neurogenic: no

psychogenic: no

What is cluttering (St. Louis et al., 2006)

cluttering is a fluency disorder characterized by a rate that is perceived to be abnormally rapid, irregular, or both for the speaker (although measured syllable rate may not exceed normal limits)

What is included in cluttering?

- excessive NSLD

- frequent pauses & prosodic patterns that do not conform to typical syntactic and semantic constraints (pauses in atypical places)

- inappropriate degrees of coarticulation (can't clearly articulate words, resulting in crunching words)

- short bursts of fast unintelligible speech

What is the prevalence of cluttering?

5% of all fluency disorders may be 'pure' clutters, but there is a significant co-occurrence of stuttering & cluttering (i.e., 30%)

Is cluttering often diagnosed earlier or later than stuttering?

diagnosed later than stuttering

What are somethings that co-occur with cluttering

- inconsistent misarticulations due to rapid rates

- ADHD frequently co-occurs

- other language problems frequently co-occurs

Are people often aware they're cluttering?

no, often not aware, affects the listener

Is any one theory of stuttering entirely correct?

No because there is a constantly changing nature to he disorder

-> providing therapy to adults is different than children

-> stuttering is very different at its onset and how it develops so different theories are required

Theories of stuttering: etiology

based on how stuttering initially developed (i.e., in childhood)

What viewpoint is etiology based on? What does this mean?

based on dysphemia viewpoint (since aristotle)

-> dysphemia: constitutional abnormality (susceptible to stuttering ex: history, temperament, slow to develop lang.)

-> e.g., stuttering thought to develop out of shock, fear, emotional pressures, insecurity, etc. If a child is predisposed to stuttering (i.e., dysphemia) then the above may 'bring out the stuttering' - not true in most cases

What are the two factors that are involved in etiology?

predisposition (hereditary/dysphemia) and precipitating (environmental)

Etiology: susceptibility (child) - constitutional/dysphemia

- predisposition for stuttering

-> e.g., family history, vulnerable or weaker language system, more sensitive temperament

Etiology: susceptibility (child) - environmental

"overbearing" parent or hurried environment

-> e.g., competition to speak

Describe the interaction between dysphemia and environment

Dysphemia & hurried environment: more likely to stutter

No dysphemia & relaxed environment: not likely to stutter

Etiology: demands and capacities, what does it mean?

demands within one area (language, motor, temperament) exceeds another aspect of the same or different area

- example: articulating faster than you can sequence sounds (motor system exceeding language capacity)

Etiology: demands and capacities, which is environmental and which is biological

Demand- environmental

Capacity- biological

Diagnosogenic (semantogenic) theory (Johnson 1940's/1950's)

- based on the notion that drawing attention to the child's disfluencies will cause the child to consider to stutter (stuttering begins in the ear of the listener)

- lead to the widespread advice to parents/from pediatricians through SLPs

-. child produces normal disfluencies -> parents perceive as STUTT -> child develops stuttering (vice versa)

Theories of stuttering: moments of stuttering

based on discrete instances of stuttering (older than 7)

-> includes psychological variables

Moment of stuttering: breakdown hypothesis (bloodstein, 1995). Is anything wrong with this theory?

- any excess of pressure, emotional stress, etc., results in stuttering

- mentions nothing about innate causes

Moment of stuttering: anticipatory-struggle hypothesis

PWS interfere in some manner with the way they are talking because they believe speech is difficult (i.e., tendency to stutter when stuttering is expected)

- the more you focus/worry about it happening, the more likely it'll happen

Moment of stuttering: anticipatory-struggle hypothesis origin

presumably stems from child's excessive hesitations, parents high standards of fluency, and communicative failures

Evaluation of children, adolescents & adults who stutter: components of an evaluation

- standardized and non-standardized measures

- goal of diagnostic: not to determine if stuttering exists but who needs it

- rationale for administering tests - know why you are testing

Evaluation of children, adolescents & adults who stutter: fluency measures

- stuttering frequency

- how large a sample of words/syllables should you collect? As many as you need

- average & variations (range)

Evaluation of children, adolescents & adults who stutter: associated measures

iterations per repetition

Evaluation of children adolescents & adults who stutter: fluency measures - things to consider doing diagnosis

intelligibility, impact of stuttering, and caregiver concern

Evaluation of children, adolescents & adults who stutter: most frequent disfluency type

- SSR & WWR (best)

- prolongations (worst)

Evaluation of children, adolescents & adults who stutter: what is stuttering duration

how long SLD's are

Evaluation of children, adolescents & adults who stutter: fluency measures- online vs offline

online- live (one watch)

offline- not live (can watch over and over)

Stuttering Severity Instrument - 4 (SSI-4)

- most common test for stuttering severity

- assesses behaviors (what you see)

- assesses stuttering frequency (how much), duration (how long it lasts), and concomitant behaviors

What are the pros and cons of the SSI-4

pros: its a standardized and normed test for the whole lifespan

cons: it doesn't measure affective/cognitive aspects; doesn't define stuttering

Components of an evaluation: recommendations

trying to decide who is the best candidate for therapy since we cant provide therapy to everyone

- predictable: can you predict when it's going to happen (more predictable = better candidate)

- persistent: does it continue to occur

- consistent: Is the frequency of SLD's consistent (higher = better candidate)

What are some questions asked by parents?

- is therapy warranted? (is the concern enough for therapy)

- if so, what kind of therapy? (older = direct, child = indirect)

- how long will it take? (shorter for younger, longer for older)

- will stuttering go away? (don't know for sure, no cure)

Some standard recommendations for younger children (conture, 2001)

- parents make no corrections/don't interrupt when child stutters

- parents model slower speech rate

- parents increase their pause time between what child says and their reply

- parents model correct articulation

- engage in non-speech activities

Therapy- evidence based practice

need to establish a basis for what you're doing in therapy

Goal of any stuttering therapy group

- being able to communicate WHAT, WHERE, WHEN, WHY, & HOW without stuttering interfering

- not 100% fluency!

Goals for clinicians

- Empathy, warmness, genuineness, ability to listen, adjust and be flexible, and make quick behavioral observations

- Focus on the individual (behavior), not on the therapy technique

- willingness to take risks - pushing/challenging client or parent

- helping client be proactive rather than reactive in the moment of stuttering

Therapy - counseling all ages of PWS & parents

- listening & responding to what the client says rather than lead

- your goal is to help your clients/parents to learn how to help themselves

- try not to rescue or deny feelings; feelings are what they are

- sympathy (feeling sorry) vs empathy (understanding feelings) vs compassion (understand feelings & can guide them)

- at what point to you refer to a mental health specialist - refer if not in your scope

- calibrating the client: learning what it's like to be a PWS

- understanding various treatment approaches before choosing or dismissing them

Goals for clients

being ready and willing for speech therapy (parents and children)

Direct therapy (elementary school age children)- which type of child is this approach most often used in?

- child and parent behavior "severe"

- when simply modeling isn't enough

- parent counseling used here too

What are the 3 basic types of direct therapy?

1. stuttering modification

2. fluency shaping

3. combination

What is stuttering modification?

focus on modifying & desensitizing person to the moment of stuttering

-> stutter acceptance - teach them how to stutter well

What is fluency shaping?

focus on altering the entirety of speech to establish fluency with little emphasis on counseling -> getting rid of therapy

-> doesn't focus on neurodiversity

Fluency shaping goals targeted

- establish good normal breath flow

- work on a variety of strategies, e.g.,

-> continuous phonation

-> stretched speech

ex: work on continuous phonation then stretched speech but doesn't get 90% accuracy so you backtrack - starts with two word utterances and progressing to sentences with improvement

what is the difference between stuttering modification and fluency shaping?

- stuttering modification: moments of stuttering, acceptable stuttering, changing attitudes, loosely structed tx

- fluency shaping: fluency skills, controlled fluency, little change in attitude, tightly structured tx

What is combination of stuttering modification and fluency shaping?

- e.g., teaching a client to use continuous phonation (fluency shaping) but also pull outs (stuttering modification); in addition spend time discussing attitudes/feelings

Goals for child

- becoming aware first (identification) then changing it (modification)

- goal is to work on something that is difficult when it's hard to see them since speech does by so quick

-teaching the child some behaviors can change but not all (sympathetic nervous system reactions)

Goals for child: should you work on primary or secondary behaviors?

Work on primary behaviors not secondary

Goals for child: age appropriate materials

Teach speech mechanism through age appropriate materials

-> where does constriction occur? Garden hose analogy of vocal tract (hose-lips; nose-vocal tract; connection to spigot-vocal folds) - can get stuck anywhere

-> demonstrate first where articulators are getting stuck

Goals for child: what are two ways we can teach children to try and fix a stutter? Give an analogy

blast through it or ease out of it

-> releasing air from balloon: pinching neck to slowly release air (ease out of it/proactive); letting it go (blasting through it/reactive)

Goals for child: how is speed when talking important in therapy?

start robotic and then move to natural