CMD 460- Fluency disorders

Fluency

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

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:

1. stuttering

2. cluttering

stuttering

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

-most common fluency disorder

-affect the rate and rhythm of speech and may be accompanied by negative reactions to speaking, avoidance behaviors, escape behaviors and physical tension

specific types of stuttering disfluencies:

o   Repetition of sounds, syllables, and monosyllabic words (e.g. look at the b-b-baby,” “lets go out-out-out”)

o   Prolongations of  consonants when it isn’t for emphasis (e.g., ssssssssometimes we stay home”)

o   Blocks (inaudible or silent fixation or inability to initiate sounds)

guitar’s stuttering definition

characterized by an unusually high frequency or duration of repetitions, prolongations, and/or blockages that interrupt the flow of speech

Stuttering facts

-95% of children who stutter start before the age of 4

-Approximately 88-91% of children who show disfluencies will recover spontaneously

-onset may be progressive or sudden

Typical disfluencies at age 2 and 3

o   Whole-word repetition (i-i-I want a cookie)

o   Interjections (can we-uhm-go now?)

o   Syllable repetitions (I like ba-baseball)

o   Revisions (“he cant- he wont play baseball”)

speech of preschoolers is often marked by disfluencies:

o   Due to the difficult motor patterns that must be refined during speech development

o   Repetition of the first word in sentences is the most common form

o   The amount of disfluency declines over time for the majority of children

o   Some children show increased disfluencies with atypical disfluency types

Warning sign

an average of 3 or more within-word disfluencies per 100 words

-frustration about speech

core speech behaviors (signs and symptoms of stuttering)

-monosyllabic whole-word repetitions

-part-word or sound/syllable repetitions

-Prolongation of consonants when it isn’t for emphasis

-blocking

-Production of words with an excess of physical tension or struggle

-Clustered disfluencies

Part-word or sound/syllable repetitions

“look at the b-b-boy”: ba-ba-ba-ba-baseball”

Prolongation of consonants when it isn’t for emphasis

“ssssssometimes we stay home”)

Blocking

inaudible or silent fixations or inability to initiate sounds

Clustered disfluencies

when the instance contains more than one type of within-word disfluencies (e.g., m-m-m-mmmmmommy)

avoidance or escape behaviors

o   Using fillers (e.g., “like”, “um”, “uh”, “you know”)

o   Avoiding sounds or words (e.g., substituting words, inserting unnecessary words, circumlocution)

o   Altering rate of speech

      Other observable, secondary stuttering behaviors can include:

o   Body movements (e.g. head nodding), facial grimaces, and distracting sounds (e.g., throat clearing)- behaviors often used unsuccessfully to stop or avoid stuttering

secondary characteristics or accessory behaviors

behaviors often used unsuccessfully to stop or avoid stuttering

stuttering onset

between 2-5

- 75% of the risk of developing stuttering occurs before the child is 3 ½ years old

 -Gradually onset and slowly increasing severity over time for majority of children

developmental framework

phase 1

-      Periods of stuttering followed by periods of relative fluency

Phase 2

-      Stuttering is essentially chronic, or habitual, with few intervals of fluent speech

Phase 3

-      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.

Phase 4

-      Certain sounds, words, and speaking situations are feared and avoided, word substitutions and circumlocutions are frequent, and there is evidence of embarrassment

Individual variability

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

stutterers as a group are more likely to:

o   Have negative concepts of themselves as a communicator (emotional)

o   Stutter on words in long, complex  sentences and/or words critical to the communication context (linguistic)

o   Have difficulty in their motor system that interferes with their ability to react rapidly (i.e., less efficient motor system)

o   Have more R hemisphere activity during speech than nonstutterers

stuttering development

      Stuttering often begins 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

      When motor pathways can’t keep up with language signals, stuttering can occur

·      In other words, imbalance between the demands for fluency and the child’s capacity to produce fluent speech might cause disfluency

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 outcomes

neurophysiological factors

Studies have shown that both structural and functional neurological differences in children who stutter. These differences include:

o   Reduced left gray matter volume with reduced white matter integrity in the L hemisphere in children with persistent stuttering

o   Reduced neural network connectivity in areas that support the timing of movement control may affect speech planning needed for fluency

o   More right hemisphere activity with less activity in the left hemisphere in adults and children who stutter

o   Reduced regional blood flow in Broca’s area (linked to speech production)

chronic stuttering

Factors that might contribute to chronic stuttering include:

o   Negative feelings and attitudes

  Frustration and embarrassment about their communication abilities

o   Avoidance

  Avoiding difficult words and speaking situations that tend to exacerbate stuttering

o   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 3 ½ years or later

-Slower rates of language development

when does an SLP conduct a comprehensive assessment?

o   There is a family history of stuttering

o   There is a parent/individual concern

o   The person exhibits negative reactions to their disfluency

o   The person is experiencing negative reactions from others

o   The person exhibits physical tension or secondary behaviors associated with the disfluency

o   The person is having difficulty communicating in an efficient, effective manner

o   Other speech or language concerns are also present

clinical understandning before the assessment

-Avoidance and escape behaviors can camouflage stuttering symptoms

-Therefore, a comprehensive assessment should assess both overt and convert features

-The affective, behavioral, and congenital 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

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 productions, receptive and expressive language, pragmatic language, etc.

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

-Judgements 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

o   Being able to decode vs. difficulty decoding the printed words

o   Reading aloud may increase disfluency rates

o   Oral reading may not be a valid measure of reading fluency for children who stutter

stuttering and language difficulties

o   Children with language difficulties might be disfluent at times but these interruptions are like to be those of typical disfluencies

o   Word finding problems can result in an increase in typical disfluencies

impact of fluency disorders on particiapation in everyday actiivities

-social and emotional

-acadmic

-vocational

social and emotional impact

difficulty having conversations or telling stories; forming friendships; regarding emotions; showing confidence

academic impact

difficulty reading aloud; answering questions in class; giving class or word presentations; participating in class discussions

vocational impact

o   May influence an individual’s perception of their career possibilities and professional limitations

o   Time pressure for verbal communication and need to use the phone may lead to stress/ discomfort

o   PWS report experiencing limitations, discrimination, and glass ceiling-like effects at their jobs

o   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

-Fluency of stuttering (# of within-word disfluencies / # of words) x 100

-Frequency of each type of disfluency

-Consistency and adaptation

o   Consistency: stuttering on the same words during multiple readings

o   Adaptation: overall reduced stuttering across multiple readings

-Feelings and attitudes

-Diagnosis and recommendations during a feedback conference

consistency

stuttering on the same words during multiple readings

adaptation

overall reduced stuttering across multiple readings

focus of treatment

-Most negative 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 experiences

-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

-Parents and family involvement in the Tx process is essential, as is a homne component

-The SLP help create a home environment that facilitates fluency and that helps them develop healthy and appropriate communication attitudes

Goals of treatment may be:

o   1. To eliminate, greatly reduce, or help the child manage their stuttering

o   2. To help them not develop negative emotional reactions related to their stuttering

Treatment approaches for preschool PWS

-indirect treatment

-direct Treatment

-opearant treatment

Indirect treatment

o   Focuses on counseling families about how to make changes in parents and child’s environment

o   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

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

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

operant treatment

o   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)

o   Parents are trained to provide verbal contingencies in response to fluent or stuttered speech

treatment focus for 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)

      Treatment is focused on:

o   Increasing effective and efficient communication

o   Increasing acceptance and openness with stuttering

o   Reducing secondary behaviors and minimizing avoidances

o   Improving social communication

o   Increasing self-confidence and self-efficacy

o   Managing bullying effectively

o   Minimizing the adverse impact of stuttering

treatment considerations for adolescents and adults

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

o   Emotional reactivity, resistance to authority, and social awkwardness, peer pressure/bullying

o   The attitudes of high school peers toward stuttering and towards PWS can be improved though education in the form of classroom presentations about stuttering

Adults with fluency disorders likely have:

o   Experienced years of treatment with varied outcomes

o   Have long-held beliefs about stuttering that positively and negatively affect self-perceptions about their communication skills and their motivation for change

o   The impact of fluency disorders often extends to social and vocational aspects of the individuals life

Treatment considerations for adults

The SLP needs to consider the impact of disfluency on communication and quality of lide 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:

o   Self-acceptance and fear reduction

o   Unrestricted interactions

o   A sense of freedom

o   Optimism

o   Continued management

treatment approaches for school age children, adolescents and adults

·      All approaches should include a plan for generalization and maintenance of skills

      Many children use an integration of approaches to achieve optimal outcomes

      Two strategies addressing the impairment in function:

   Speech modification

o   Stuttering modification

      Increasing speech efficiency (reducing word avoidance)

      Strategies for reducing reactions (personal and environmental context)

o   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

-easy/ gentle onset

-light articulatory contact

-continuous phonation

-prolonged syllables

-rate control

      Aim to reduce physical tension and struggle by helping the PWS identify core stuttering behaviors, recognize physical behaviors, locate the point of tension and struggle during moments of disfluency, and ultimately reduce the tension

      Primary goal: to help stutterers acquire a speech style they find to be acceptable

      Belief: attitudes and feelings about stuttering play a critical role in the development, continuation and remediation of stuttering

easy/ gentle onset

the gradual onset of voicing (on initial vowels)

light articulatory contact

maintaining voicing throughout utterance

continuous phonation

maintaining voicing throughout utterance

prolonged syllables

stretching each syllable in words/utterance

rate control

slowing the overall rate of speech

traditional stuttering modifications strategies

-cancellation

-pull-out

-preparatory set

cancellation

after a stuttered word, the speaker pauses to examine the physical features of the stuttered word and then adjust 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