Final Fluency Disorders (Based on the PowerPoints)

Stuttering genetic factors

Stuttering tends to be inherited (chromosomes 9, 15, and 12 genes are associated with stuttering).

Neurophysiological factors

Brain imaging studies have shown differences in brain structure and function in individuals who stutter, such as differences in the left hemisphere's white matter tracts involved in speech processing.

Early childhood factors

Brain injury, premature birth, and intense fear are among the factors linked to stuttering in individuals without a family history of the condition.

Sensory Processing Factors

Individuals who stutter often exhibit deficits in auditory processing, including poorer speech perception and slower reaction times to linguistic stimuli.

Sensorimotor Control

People who stutter generally have slower motor responses, including slower speech rates and longer vowel durations, which might be linked to their stuttering.

Language Factors

Stuttering often begins during rapid language development in children. More complex language tends to increase the likelihood of stuttering.

Emotional Factors

Emotional reactivity and anxiety are higher in individuals who stutter, likely as a result of their stuttering experiences.

Developmental Factors

Rapid physical and motor development in children can compete for neural resources, potentially increasing stuttering.

Children with advanced motor control may recover naturally from stuttering.

Environmental Factors

Environmental factors such as parental interaction styles, speech models, and stressful life events can trigger or exacerbate stuttering.

The Purpose of Theories

Theories provide a systematic way to explain and predict phenomena. In stuttering, there are multiple theoretical perspectives rather than one unified theory.

Orton and Travis (1931)

Lack of hemispheric dominance causes mistiming of muscle activation, leading to stuttering.

Geschwind and Galaburda (1985)

A delay in left hemisphere development causes inefficient speech processing.

Webster (1983)

The left hemisphere’s supplementary motor area, crucial for movement planning and sequencing, is vulnerable to disruption, leading to stuttering.

Van Riper (1982)

Stuttering results from disruptions in the timing of muscle sequencing.

Kent (1994)

Central timing deficits in the brain affect the integration of speech production, leading to stuttering.

Neilson and Neilson (1987)

Stuttering may result from a weakness in using an internal model to translate auditory targets into motor commands for speech.

Wingate (1988), Perkins, Kent, and Curlee (1991)

Stuttering arises from difficulties in planning and assembling language units.

Kolk and Postma (1997)

Internal monitoring of language production detects errors, leading to stuttering as the speaker attempts to correct these errors.

Diagnosogenic Theory

Suggests that stuttering develops when normal disfluencies are misinterpreted as stuttering by parents, leading to increased tension and effort by the child, an idea that focuses on environmental factors.

Capacities and Demands

Stuttering occurs when a child's capacity for fluent speech is overwhelmed by environmental or internal demands.

Communicative Failure and Anticipatory Struggle

Stuttering begins when a child anticipates difficulty in speaking, leading to tension and fragmented speech.

Stuttering may develop in two stages

a primary stage involving simple disfluencies and a secondary stage characterized by increased tension, escape, and avoidance behaviors due to environmental reactions and the child’s temperament.

Developmental Levels of Stuttering

- Typical Disfluency (Ages 1.5 to 6)

- Borderline Stuttering (Ages 1.5 to 3.5)

- Beginning Stuttering (Ages 3.5 to 6)

- Intermediate Stuttering (Ages 6 to 13)

- Advanced Stuttering (Ages 14 and above)

Classical conditioning

links the emotions associated with stuttering to more situations, increasing tension.

Operant conditioning

reinforces escape behaviors.

Avoidance conditioning

leads to avoidance of words or situations that might cause stuttering.

Comprehensive Approach

Assessment should involve careful planning, observation, and analysis, considering the client as a whole person.

Client-Centered Focus

It's important to understand the client's goals and maintain an open perspective, avoiding preconceived notions from past cases.

Cultural Considerations

Clinicians should be culturally sensitive, understanding differences in communication styles, eye contact, family interactions, and the use of interpreters.

Assessment of Stuttering Behavior

- Speech sample
- Frequency and types of stutters
- Duration
- Secondary behavior

Speech Sample

Collect speech samples in different settings to capture variability in stuttering. Use video recordings and ensure samples are long enough to be representative.

Frequency and Types of Stutters

Measure stuttering frequency as a percentage of syllables stuttered (%SS). Identify stutter-like disfluencies and assess their frequency.

Duration

Measure the duration of the three longest stutters to assess severity.

Secondary Behaviors

Differentiate between escape behaviors (e.g., eye blinks) and avoidance behaviors (e.g., word substitutions) and include them in the severity assessment.

To assess stuttering severity

tools like the SSI-4, Scale for Rating Severity of Stuttering, and Test of Childhood Stuttering (TOCS) are used. Attitudes and feelings are also assessed, particularly in school-age children and adults, using tools like the KiddyCAT and OASES.

Assessing preschool children

Indirect Therapy: Focuses on modifying the child’s environment to reduce communication pressure, such as slowing down the speech rate and increasing turn-taking in conversations.

Parental Involvement: Educating and involving parents in the treatment process, helping them create a supportive and relaxed speaking environment at home.

Play-Based Therapy: Using games and play to encourage fluent speech and reduce the child’s awareness of stuttering.

Assessing School-Age Children

Fluency Shaping: Introducing techniques like gentle onsets, slow speech rate, and light articulatory contacts to improve fluency.

Desensitization: Gradually exposing children to feared speaking situations in a controlled way to reduce anxiety.

Counseling: Addressing emotional aspects of stuttering, such as feelings of embarrassment or frustration, to build resilience and confidence.

Assessing adolescents

Stuttering Modification: Teaching adolescents techniques to manage and control their stuttering, such as pull-outs and cancellations.

Peer Support Groups: Encouraging participation in support groups where they can share experiences and learn from others who stutter.

Goal Setting: Helping adolescents set personal goals for their speech and develop strategies to achieve them.

Assessing adults

Cognitive Behavioral Therapy (CBT): Addressing negative thoughts and feelings associated with stuttering, such as anxiety, fear, or avoidance behaviors.

Fluency Shaping and Stuttering Modification: Combining techniques to enhance fluency and reduce stuttering severity, depending on the individual's preferences and needs.

Support Networks: Encouraging participation in support groups or connecting with other adults who stutter to share experiences and coping strategies.

Younger Preschool Children (Borderline Stuttering) Ages 1.5 to 3.5

Behaviors: Repetitions of sounds, syllables, and whole words, usually without tension or struggle. Disfluencies are more frequent than in typically fluent children but not yet characterized by secondary behaviors.

Thoughts/Emotions: Little to no awareness of stuttering, and thus no negative feelings or emotions associated with it.

Borderline stuttering clinical approach

Indirect Treatment: This treatment focuses on educating and counseling parents to create a fluency-facilitating environment. Key strategies include adjusting the parent’s speech rate, reducing questions, and improving the communication environment.

Severity Ratings: Parents are taught to use a severity rating scale to track the child's stuttering daily.

Maintenance: Continue supporting the family after fluency is achieved, gradually fading contact but staying open to future support if needed.

Older Preschool Children (Beginning Stuttering) Ages 3.5 to 6

Behaviors: Increased frequency of disfluencies with the addition of prolongations and blocks. Some struggle may be present, with the emergence of secondary behaviors such as eye blinks or other physical movements.

Thoughts/Emotions: Awareness of stuttering begins, leading to frustration. The child may begin to show signs of frustration or embarrassment.

Parent-Delivered Program

Parents deliver treatment at home, praising fluent speech and gently correcting stutters. Weekly clinic visits and daily severity ratings guide the program.

Lidcombe program

A parent-administered treatment in which positive reinforcement is provided for stutter-free speech, and correction is used following stuttering.

Clinician's Attributes

- Empathy
- Warmth
- Genuineness
- Preference for EBP
- Commitment to continuing education
- Critical thinking and creativity

Treatment goals for stuttering

- Reduce frequency of stuttering
- Reduce abnormality
- Reduce negative feelings and attitudes
- Reduce avoidance behaviors
- Increase communication abilities
- Create a facilitating environment

Therapy procedures

- Dealing with emotions
- Reducing frequency
- Reducing negative emotion
- Reducing negative thoughts and attitudes
- Reducing avoidances
- Increasing communication skills
- Creating a facilitating environment

School-Age Children (Intermediate Stuttering) Ages 6 to 13

Behaviors: More consistent and severe blocks and prolongations. Secondary behaviors become more established as the child tries to escape or avoid stuttering moments (e.g., avoiding certain words or situations).

Thoughts/Emotions: Significant awareness of stuttering, leading to fear, embarrassment, and avoidance. The child may start to develop negative attitudes towards speaking and may avoid speaking situations altogether.

Clinical procedures for intermediate stuttering

- Exploration
- Changing core behaviors
- Openness and acceptance
- Voluntary stuttering
- Desensitizing to fluency disrupters
- Reducing fear and avoidance
- Coping with teasing
- Maintaining improvement

Adolescents and Adults (Advanced Stuttering)

Behaviors: Severe and frequent blocks, often accompanied by complex secondary behaviors. The individual might develop strategies to avoid stuttering, such as word substitutions or avoiding speaking situations entirely.

Thoughts/Emotions: Deep-seated fear and shame associated with stuttering. The individual may feel a lack of control over their speech and may experience significant anxiety about speaking.

Stuttering modification

The focus is on managing and accepting stuttering rather than eliminating it. Techniques such as cancellations, pull-outs and preparatory sets are utilized.

When to Choose: This approach is often chosen for individuals who have significant fear, anxiety, and avoidance behaviors associated with stuttering.

Key components for advance stuttering

- Exploring stuttering
- Reducing negative emotions
- Increasing approach behaviors
- Fluency shaping

Maintenance for advance stuttering

Becoming Own Clinician: Clients are taught to self-evaluate and reinforce their behavior, setting goals and assignments to maintain progress.

Long-Term Therapy: Progress is maintained through long-term therapy, gradually fading clinician contact, and continuing to address any re-emerging stuttering behaviors.

Establishing Goals: Clients work with the clinician to establish realistic long-term goals, such as achieving controlled fluency or accepting mild stuttering.

Neurogenic acquired stuttering

Nature: Caused by neurological conditions like stroke, head trauma, or diseases such as Parkinson’s.

Diagnosis: Involves a detailed case history, direct assessment of speech, and ruling out other neurological or psychological issues.

Treatment for neurogenic acquired stuttering

Techniques include pacing, masking, slow rate and easy onset, and stuttering modification. Some cases may require surgical or pharmacological interventions.

Psychogenic Acquired Stuttering

Nature: Typically occurs after prolonged stress or trauma and is not a deliberate behavior. It may present with unusual secondary behaviors and become more severe under fluency-inducing conditions.

Diagnosis: This requires a multidisciplinary approach, including a thorough case history, motor-speech exam, and analysis of stuttering behaviors. Trial therapy is used to assess response.

Treatment for psychogenic acquired stuttering

Combines psychotherapy with stuttering modification or fluency shaping. Successful candidates often show significant improvement with trial therapy.

Cluttering

Nature: Characterized by a rapid, disorganized speech pattern with frequent normal disfluencies. Cluttering often co-occurs with developmental stuttering and may involve disorganized language and learning issues.

Diagnosis: Assessment includes videotaped speech tasks, language assessment, and identification of coexisting disorders. It is important to evaluate intelligibility and speech rate.

Treatment for cluttering

This treatment focuses on increasing awareness of speech rate, improving linguistic skills, and enhancing fluency. Techniques may include matching speech rate to a model, using visual feedback, and working on intelligibility through structured speech tasks.

Exploring stuttering

Clients work on becoming comfortable with their stuttering through exploration and staying in the moment of stuttering.

Reducing Negative Emotions

Therapy focuses on reducing fear, shame, and negative thoughts through cognitive therapy and voluntary stuttering techniques.

Increasing Approach Behaviors

Clients are encouraged to face feared speaking situations, gradually reducing avoidance.

Fluency Shaping

Focuses on changing the overall speech pattern to increase fluency and reduce stuttering. The goal is to eliminate stuttering by teaching a new way of speaking. Techniques such as slow speech rate, gentle onsets, light articulatory contacts and proprioceptive feedback are utilized.

When to Choose: This approach is often chosen for individuals who want to focus on increasing fluency and reducing stuttering through behavioral techniques.

Blocks

tension or pause

Prolongations

a type of disfluency in which a sound is held out or prolonged for an unusually long time

repetitions

repeated syllables in a word trying to be said (ie: b-b-b-b-baseball, I-I-I-I-I like baseball)

Voluntary Stuttering

Encourage the child to practice voluntary stuttering in a controlled, positive way to increase mastery over their speech.

Desensitizing to Fluency Disrupters

Use role-playing and other techniques to help the child cope with disruptions to their fluency.

Disorder of Brain Organization

This theory suggests that stuttering is linked to atypical neural organization, possibly due to genetic factors that affect brain development.

Timing Deficit Theory

Proposes that stuttering results from a disruption in the timing of motor control, which could be linked to neurophysiological differences in the brain.

Capacities and Demands Model

This model posits that stuttering occurs when the demands placed on a child’s speech and language systems exceed their capacities, integrating both developmental and environmental factors.

Cancellations

After a stuttered word, the individual pauses, then repeats the word in a more controlled manner.

Pull-outs

During a stutter, the individual gradually reduces tension and completes the word smoothly.

Preparatory Sets

Anticipating a stutter and easing into the word with less tension.

Slow Speech Rate

Slowing down speech to increase fluency.

Gentle Onsets

Initiating speech with a gentle, easy start to reduce tension.

Light Articulatory Contacts

Using light touches of the articulators (lips, tongue, etc.) to prevent hard contacts that can lead to stuttering.

Proprioceptive Feedback

Increasing awareness of the physical aspects of speech production.

Integrated approaches

Combine elements of both stuttering modification and fluency shaping, recognizing that different clients may need different strategies at different times. The goal is to provide a flexible and individualized approach to therapy. Techniques is a combination of stuttering modification and fluency.

When to Choose: This approach is suitable for clients who need a more tailored therapy plan that addresses both the emotional aspects of stuttering and the development of fluent speech patterns.

PWS

person who stutters or individuals who stutters

Counseling for PWS

- Emotional support
- Building confidence
- Managing anxiety
- Promoting openness

Counseling for PWS's families

- Education
- Supportive environment
- Coping strategies
- Sibling and peer relationships