CMD fluency disorders

Fluency

the term describes speech that is easy, rapid, rhythmical, and evenly flowing

All speakers are disfluent at times

typical disfluencies

A fluency disorder

Is an interruption in the flow of speaking characterized by atypical rate, rhythm, and disfluencies, and other behaviors

Two types of fluency disorders

Stuttering + Cluttering

Is stuttering the most common fluency disorder

yes

what is stuttering

Is an interruption in the flow of speaking characterized by specific types of disfluencies

stuttering

• Repetition of sounds, syllables, and monosyllabic words

• Prolongations of consonants when it isn’t for emphasis

• Blocks

how would these disfluencies can affect the rate and rhythm of speech

may be accompanied by negative reactions to speaking, avoidance behaviors, escape behaviors, and physical tension.

Guitar’s Three-part Definition

Characterized by an unusually high frequency or duration of repetitions, prolongations, and/or blockages that interrupt the flow of speech
◦ The interruptions are often combined with excessive mental and physical effort to resume talking
◦ Most stutterers have negative perceptions of their communication abilities

what do people often experience

psychological, emotional, social, and functional consequences from their stuttering

Social anxiety

a sense of loss of control, negative thoughts/feelings about themselves or communication

what age do 95% of children who stutter start by

the age of 4 (average age of onset = 33 months); more prevalent in boys than girls

what does the onset of stuttering look like

may be progressive or sudden

approximately 88-91% of children who show disfluencies

will recover spontaneously with or without intervention.
◦ Stuttering can co-occur with other disorders (e.g., ADHD, ASD, intellectual disability)

Incidence

the number of new cases identified in a specific time period

Prevalence

the number of individuals who are living with fluency disorders in a given time period

A recent US study

approximately 2% of children ages 3-17 years stutter

Children with a family history were estimated to be how much likely to persist in stuttering

1.89 times more likely

what ages do typical disfluencies appear 

at ages 2-3

what are the typical disfluencies

Whole-word repetition (I-I-I want a cookie.)
◦ Interjections (Can we-uhm-go now?)
◦ Syllable repetitions (I like ba-baseball.)
◦ Revisions (“He can’t – he won’t play baseball.”

Normal disfluencies do not tend to adversely affect

the continuous forward flow of speech.

what does these disfluencies involve

within-word disruptions tend to be judged as
stuttering by listeners.
◦ ** On the other hand, the primary stuttering behaviors (“core behaviors”) are disfluencies which are not typical.

Speech of preschoolers is often marked by disfluencies:

Due to the difficult motor patterns that must be refined during speech development
◦ Repetition of the first word in sentences is the most common form
◦ The amount of disfluency declines over time for the majority of children
◦ Some children show increased disfluencies with atypical disfluency types.

An average of 3 or more

within-word disfluencies (i.e., sound repetitions,
prolongations, or blocks) per 100 words might be a warning sign.

• Stuttering children might show feelings of frustration about their speech and begin to develop secondary stuttering behaviors.

• A predisposition for stuttering may be inherited.

Core speech behaviors

• monosyllabic whole-word repetitions (e.g., “Why-why-why did he go there?”)

• part-word or sound/syllable repetitions (e.g., “Look at the b-b-boy”; ba-ba-ba-ba-baseball”)

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

• blocking (i.e., inaudible or silent fixations or inability to initiate sounds)

• production of words with an excess of physical tension or struggle

• Clustered disfluencies – when the instance contains more than one type of within-word disfluencies

Avoidance or Escape Behaviors, what is that called 

secondary characteristics or accessory behaviors – behaviors often used unsuccessfully to stop or avoid stuttering

observable, secondary stuttering behaviors can include

Body movements (e.g., head nodding), facial grimaces, and distracting sounds (e.g., throat clearing) – behaviors often used unsuccessfully to stop or avoid stuttering
◦ Becoming automatic, less successful, and distracting over time
◦ Efforts to conceal stuttering may adversely affect quality of life

when does onset and development of stuttering

b/t 2 & 5

what percentage of the risk of developing stuttering occurs b/t the child is 3 ½ years old

75% of the risk of developing stuttering occurs b/t the child is 3 ½ years old.
◦ Gradual onset and slowly increasing severity over time for majority of children

1st phase of developmental framework

corresponds to the preschool years, roughly b/t the ages of 2 & 6. Periods of stuttering followed by periods of relative fluency. The episodic nature of stuttering is an indication that stuttering is in its most rudimentary form.
- Most children are unaware of the interruptions

2nd phase of development framework

represents a progression of the disorder and is associated with children of elementary school age. Stuttering is essentially chronic, or habitual, with few intervals of fluent speech

3rd phase of developmental framework

associated with individuals who can range in age from about 8 years to young adulthood. Stuttering seems to be in response to specific situations such as speaking to strangers, speaking in front of groups, or talking on the telephone. Certain words are regarded as more difficult than others, and the person who stutters attempts to avoid such words by using word substitutions and circumlocutions. Ex. “I want a ni-ni-ni-five cents”. Despite the individual’s awareness of stuttering, he or she will generally present little evidence of fear or embarrassment and will not avoid specific speaking situations

4th phase of developmental framework

stuttering is in its most advanced form. A primary characteristic is vivid and fearful anticipation of stuttering. Certain sounds, words, and speaking situations are feared and avoided, word substitutions and circumlocutions are
frequent, and there is evidence of embarrassment

Does stuttering always develop gradually

No. For some individuals, when stuttering is first diagnosed in young children, the symptoms appear to be very advanced and secondary characteristics may be present.

Individual variability

the manner, frequency, and context one stutters
might be different from another stutterer

Stutterers as a group are more likely to

Have negative concepts of themselves as a communicator (emotional)
◦ Stutter on words in long, complex sentences and/or words critical to the
communication context (linguistic)
◦ Have difficulty in their motor system that interferes with their ability to react
rapidly (i.e., less efficient motor system)
◦ Have more R hemisphere activity during speech than nonstutterers

What would the cause of stuttering thought to be

multifactorial

when does stuttering often begin

when children’s language abilities are rapidly
expanding.

As children produce longer and more complex sentences

their brain experiences higher demand. This increased demand can affect the motor control necessary to produce speech.

Genetic Factors

• Some studies support a genetic predisposition for stuttering

• However, researchers haven’t pinpointed a specific gene that’s
  solely responsible for stuttering.

• However, several likely gene mutations have been linked to stuttering (e.g., NPTAB, GNPTG, NAGPA).

• Genetic factors also may play a role in predicting the likelihood of persistence or recovery, and possibly, treatment.

For neurophysiological factors, what do studies show

that both structural and functional neurological
differences in children who stutter.

for neurophysiological factors, these differences include:

Reduced left gray matter volume with reduced white matter integrity in the L hemisphere in children with persistent stuttering
◦ Reduced neural network connectivity in areas that support the timing of movement control à may affect speech planning needed for fluency
◦ More right hemisphere activity with less activity in the left hemisphere in adults and children who stutter
◦ Reduced regional blood flow in Broca’s area (linked to speech production)

how can stuttering be resolved

related to growth spurts in developmental domains – speech motor control, language, cognition, temperament.

Factors that Might Contribute to Chronic Stuttering include:

Negative feelings and attitudes
◦ Frustration and embarrassment about their communication abilities
◦ Avoidance
◦ Avoiding difficult words and speaking situations that tend to exacerbate stuttering
◦ Difficulties with speech motor control
◦ Unusual patterns of breathing, vocalizing, and speaking

Risk Factors Associated with Persistent Stuttering

• sex of child—boys are at higher risk for persistence of stuttering than girls

• family history of persistent stuttering

• time duration of greater than 6–12 months since onset or no improvement over several months

• age of onset—children who start stuttering at age 3½ years or later

• slower rates of language development

When disfluencies are noted and when one or more of the factors listed below are observed

There is a family history of stuttering.
◦ There is parent/individual concern.
◦ The person exhibits negative reactions to to their disfluency.
◦ The person is experiencing negative reactions from others.
◦ The person exhibits physical tension or secondary behaviors associated with the
disfluency.
◦ The person is having difficulty communicating in an efficient, effective manner.
◦ Other speech or language concerns are also present.

Clinician Understanding Before the Assessment

Symptoms and severity of stuttering van vary across different situations.
◦ Avoidance and Escape behaviors can camouflage stuttering symptoms.
◦ Therefore, a comprehensive assessment should assess both overt and covert features.
◦ The affective, behavioral, and cognitive features of stuttering are important
components of the assessment.
◦ Clinicians need to be observant of indicators.
◦ It is ideal to collect samples of speech across various situations and tasks, both inside
and outside the clinical setting.
◦ Audiovisual recordings of speech can provide useful information to supplement direct
clinical observation.
◦ Stuttering do not need to occur in all situations or even a majority of the time to be
diagnosable disorders.

A Comprehensive Assessment: Components

Relevant case history (as appropriate for age)
◦ Consultations with family members and educators regarding fluency variability and the
impact of disfluency
◦ Review of previous fluency evaluations and educational records
◦ Assessment of speech fluency (frequency, type, duration), speech rate, speech
intelligibility, and the presence of secondary behaviors in a variety of speaking tasks
Assessment of awareness in young children of disfluencies and difficulty in speaking
◦ Stimulability testing
◦ Assessment of the impact of stuttering – emotional, cognitive, and attitudinal impact of
disfluency
◦ Assessment of other communication dimensions – speech sound production,
receptive and expressive language, pragmatic language, etc.

what kind of information would be included in the case history

• Medical history
  ◦ General development; also speech and language development
  ◦ Speech and language concerns
  ◦ Family history of stuttering
  ◦ Description of disfluency and rating of severity
  ◦ Age or onset of disfluency and patterns of disfluency since onset (e.g., continuous or variable)
  ◦ Previous fluency treatment and treatment outcomes
  ◦ Exploration of parental reactions to the child’s moments of disfluency or speaking frustration
  ◦ Information regarding family, personal, and cultural perception of fluency

Assessment May Result In

the diagnosis of a fluency disorder (i.e., stuttering)
◦ a differential diagnosis between fluency disorders and other speech/language disorders
◦ descriptions of the characteristics and severity of stuttering
◦ judgments on the degree of impact stuttering has on verbal communication and quality
of life
◦ a determination if the person will benefit from treatment
◦ a determination of adverse educational, social, and vocational impact
◦ recommendations for treatment
◦ parent or family counseling to determine optimal responses to the child’s speech and
stuttering
◦ consultation with and referral to other professionals as needed

Stuttering and Reading Disorders

Being able to decode vs. difficulty decoding the printed words
◦ Reading aloud may increase disfluency rates
◦ Oral reading may not be a valid measure of reading fluency for children who
stutter

Stuttering and Language Difficulties

Children with language difficulties might be disfluent at times but these
interruptions are like to be those of typical disfluencies.
◦ Word finding problems can result in an increase in typical disfluencies

Social and Emotional Impact of Fluency Disorders

Having conversations or telling stories; forming friendships; regulating emotions; showing confidence

Academic Impact of Fluency Disorders

Reading aloud; answering questions in class; giving class or work presentations; participating in class discussions

Vocational Impact of Fluency Disorders

May influence an individual’s perception of their career possibilities and professional limitations
◦ Time pressure for verbal communication and need to use the phone may lead to
stress/discomfort.
◦ PWS report experiencing limitations, discrimination, and glass ceiling-like effects at
their jobs.
◦ Helping PWS become more accepting /open about their stuttering may help them
have workplace conversations about it, advocate for themselves, and build support
systems within the workplace.

Measures of Stuttering

Frequency of stuttering: (# of within-word disfluencies /# of words) x 100
◦ Frequency of each type of disfluency
◦ Consistency and adaptation
◦ Consistency: Stuttering on the same words during multiple readings
◦ Adaptation: overall reduced stuttering across multiple readings
◦ Feelings and attitudes
◦ Diagnosis and recommendations during a feedback conference

Focus of Treatment

Most individuals who stutter demonstrate both observable disfluency and negative life impact.
◦ When developing treatment goals, the clinician takes a holistic approach and considers the extent to which stuttering affects the individual’s entire communication experience.
◦ Goals that focus on minimizing negative reactions to stuttering and difficulties communicating in various speaking situations may help the individual reduce the effort used to hide or avoid their disfluencies and communicate with more ease.

Preschool Children who Stutter

Tx approaches are individualized based on the child’s needs and family communication patterns.
◦ A comprehensive Tx approach includes both parent- and child-focused strategies.

• Parent and family involvement in the tx process is essential, as is a homne
  component.
  ◦ The SLP help crate a home environment that facilitates fluency and that helps
  them develop healthy and appropriate communication attitudes

What are the goals of treatment may be for Preschool Children who Stutter

• To eliminate, greatly reduce, or help the child manage their stuttering

• To help them not develop negative emotional reactions related to their stuttering

Indirect treatment for preschool PWS

Focuses on counseling families about how to make changes in parents’ and child’s environment.
◦ The modifications used to facilitate speech fluency include: Reducing the communication rate, using indirect prompts rather than direct questions, rephrasing to model fluent speech or technique

Direct treatment for preschool PWS

• Focuses on changing the child’s speech, attitudes, and beliefs in order to manage stuttering or facilitate fluency

• May include speech modification and stuttering modification strategies to reduce disfluency rate, physical tension, and secondary behaviors.

Operant treatment (e.g., Lidcombe Program) for preschool PWS

Incorporates principles of operant conditioning (viewing stuttering as a learned behavior) and
uses a response contingency to reinforce the child for fluent speech and redirect disfluent speech
(the child is periodically asked for correction)
◦ Parents are trained to provide verbal contingencies in response to fluent or stuttered speech

School-age Children, Adolescents, and Adults Who Stutter

A Comprehensive treatment includes multiple goals and considers the age of the individual and their unique needs(e.g., communication in the classroom, in the community, at work)

What is the treatment is focused on for School-age Children, Adolescents, and Adults Who Stutter

Increasing effective and efficient communication
◦ Increasing acceptance and openness with stuttering
◦ Reducing secondary behaviors and minimizing avoidances
◦ Improving social communication
◦ Increasing self-confidence and self-efficacy
◦ Managing bullying effectively
◦ Minimizing the adverse impact of stuttering

Treatment for adolescent PWA poses a particular challenge due to the issues
related to this developmental stage such as

emotional reactivity, resistance to authority, and social awkwardness, peer pressure/bullying
◦ The attitudes of high school peers toward stuttering and toward PWS can be improved through education in the form of classroom presentations about stuttering

Adults with fluency disorders likely have

experienced years of treatment with varied outcomes
◦ have long-held beliefs about stuttering that positively or negatively affect self- perceptions about their communication skills and their motivation for change

• The impact of fluency disorders often extends to social and vocational aspects of the
  individual’s life.

what does the SLP need to consider the impact of

disfluency on communication and quality of life as a whole.
◦ Tx should consider both the overt stuttering behaviors and the affective/cognitive reactions to stuttering.

Successful stuttering management in adults have been described with the following themes:

• self-acceptance and fear reduction
  ◦ unrestricted interactions
  ◦ a sense of freedom
  ◦ optimism
  ◦ continued management

Two strategies addressing the impairment in function

Speech modification
◦ Stuttering modification
◦ Increasing Speech Efficiency (Reducing word avoidance)\
◦ Strategies for reducing negative reactions (personal and environmental context)
◦ Awareness, desensitization, cognitive restructuring, self-disclosure, and support

Speech Modification Strategies

• Include techniques aimed at making changes to the timing and tension of speech production or altering the timing of pauses between syllables
  and words

• Strategies aimed at altering the timing of pauses are used to increase the likelihood of fluent speech, to improve overall communication skills, and to control rate.

Easy/gentle onset

the gradual onset of voicing (.e.g., on initial vowels)

Light articulatory contact

using easy articulatory gestures (e.g., on plosives)

Continuous phonation

maintaining voicing throughout utterance

Prolonged syllables

“stretching” each syllable in words/utterances

Rate control

slowing the overall rate of speech

Traditional stuttering modification strategies include:

◦ Cancellation – After a stuttered word, the speaker pauses to examine the physical
features of the stuttered word and then adjusts airflow voicing, and the vocal tract
to produce an easy version of the stuttered word
◦ Pull-out – During a stuttering word, the speaker ‘slides out” of the stuttered word
by adjusting airflow, voiding, and the vocal tract to stutter smoothly through the
word
◦ Preparatory set – the PWS anticipates a moment of stuttering before it occurs
and use stuttering modification strategies to more effectively manage the moment
of stuttering while producing the word.
◦ Similar to speech modification strategies, these strategies are introduced
along a hierarchy of speaking situations that varies both with linguistic
demands and with the stressors of the environment.