Motor Speech Final Slides pt 1 - Stuttering/Cluttering

Fluency

• multidimensional construct that is based on observable actions (speech articulation) and underlying neural processing (pre linguistic conceptualization, formulation, motor planning)

• Fluency depends on both the language and speech motor processes.

• Important to have clear conceptualization of fluency in order to work with individuals who have a fluency impd.

• Need to know normal in order to know abnormal

7 Dimensions of Fluency

• Continuity

• Rate

• Rhythm

• Effort

• Naturalness

• Talkativeness

• Stability

Different Types of Fluency

• Speech Fluency

• Semantic Fluency

• Syntactic Fluency

• Pragmatic Fluency

• Breakdown in speech fluency is termed disfluencies.

• Linguistic Fluency - refers to effortless and proficiency in which a speaker selects and assembles the linguistic codes, knowledge of vocab, syntax, phoneme, morphemes

• Need to know the source of the dysfluency

Any speaker can be more or less fluent dependent on

• Demands of the communication situation

• The psychophysical state of the person

• Social/cultural norms

• Communication proficiency

• Topic knowledge and cognitive or linguistic demands

• Age and status of speech and language development

• Self-regard and Self-belief systems

Normal Disfluencies

• Hesitations (pauses for language formulation)

• Word fillers ("like") or interjections ("um")

• Phrase repetition (more than 1 word repeated)

• Whole word repetitions (2 or less)

• Revisions (change how we say a message)

Fluency Disorder

• Classified as a subtype of speech disorder, also includes difficulties in language formulation. Manifested in speech in the form of pauses, hesitations, word repetitions.

• Two common speech fluency disorders; Stuttering and Cluttering

Atypical Disfluencies Core and Secondary Behaviors

• Part-word (sound/syllable) repetitions, Single syllable whole word repetitions (>2), Prolongations & Blocks

• Avoidance, Postponement, Starters, Disguise/Conceal, Interrupter Devices, & Searching Movements /Escape behaviors

General Stuttering Guidelines

• Normal Disfluency: 1.5 - 6years

• Borderline Stuttering: 1.5 - 3.5years

• Beginning Stuttering: 3.5 - 6 years

• Intermediate Stuttering: 6 – 13years

• Advanced Stuttering: 14+ years

Normal Disfluency

• 1.5-6 years

• Core Behaviors

  • No more than 10 disfluencies per 100 words

  • Typically one to two unit repetitions

  • Mostly repetitions, interjections, & revisions

Borderline Stuttering

• 1.5-3.5 years

• Core Behaviors

  • 11 or more disfluencies / 100 words

  • Often more than 2 unit repetitions

  • More repetitions and prolongations than revisions

  • Loose, relaxed disfluencies

Contributing Factors for Typical Disfluency and Borderline Dysfluency

• Demands of language Acquistion

• Speech motor control maturation

• Family stresses

• Threats to security (death in the family, divorce, moving, birth of sibling etc)

Beginning Stuttering

• 3.5-6 years

• Core Behaviors

  • Emergence of tensing and speeding up of repetitions

  • Stuttering occurs more often in frequency

  • Pitch rise accompanies prolongations

  • Fixed articulatory postures may appear in blocks

• Secondary Behaviors

  • Escape behaviors are present (eye blinks, head jerks) as disfluency progresses

• Feelings and Attitudes

  • Awareness of difficulty and feelings of frustration are present

• Contributing Factors

  • Interplay of constitutional (predispositions)and environmental factors

  • Child's own temperament

  • Conditioned reactions causing excess tension and escape behaviors

Intermediate Stuttering

• 6-13 years

• Core Behaviors

  • Blocks in which sound and airflow are cut off

  • Increasingly tense blocks, repetitions and prolongations

• Secondary Behaviors

  • Escape behaviors

  • The emergence of avoidance and disguise behaviors

• Feelings and Attitudes

  • Fear of stuttering emerges

  • Embarrassment and shame

  • More tense blocks are met with increased listener surprise or impatience

  • Fear of listener reactions/punishment increases

• Contributing Factors

  • All previously described, plus

  • Avoidance conditioning

  • Fear before stuttering, embarrassment during stuttering, and shame after stuttering contribute to more negative experiences and feelings.

Advanced Stuttering

• 14 plus years

• Core Behaviors

  • Long tense blocks, some with tremor (involuntary muscle movements due to tension)

  • Highly over learned patterns

  • more difficult to change

  • Also see tense repetitions and prolongations

• Secondary Behaviors

  • Escape and avoidance behaviors can become more complex

• Feelings and Attitudes

  • Negative self-concept begins to be formed

• Contributing Factors

  • All previously described

  • Cognitive learning

Most common type of stuttering Is…

• neurodevelopmental stuttering also labeled as childhood stuttering, developmental stuttering

  • Onset in childhood

  • Most often occurs in pre-k years, absence of a neurological injury, trauma, illness

  • American Psychiatric Association (2013) adopted "Childhood Onset Fluency Disorder" as part of DSM-5 (Diagnostic and Statistical Manual of Mental Disorders)

  • WHO (2018) used the label "Developmental Speech Fluency Disorder" when referring to stuttering, classified under broader heading “Neurodevelopmental disorder”

  • Childhood form stuttering is different from non-developmental form of stuttering also referred to “acquired stuttering” ▪ Neurogenic, pharmacogenic, psychogenic

Possible predictors/factors

• Family History

• Gender

• Age at Onset

• Stuttering Severity and Frequency

• Duration Since Onset

• Duration of Stuttering Moments

• Presence of sound prolongations and blocks

• Phonological Skill

What causes stuttering?

• Physiological

• Linguistic

• Emotional

• Environmental

Multifactorial Framework

• Predisposing physiological and linguistic factors may be significant in the onset and development of stuttering.

• These predisposing factors interact with emotional and environmental aspects and contribute to severity, persistence and impact on child and family

What are the physiological considerations? Constitutional Makeup

• Hereditary Factors

  • Idea of stuttering is inherited recognized since 1935 by Bryngelson

    • Studies suggest stuttering usually runs in families;

      • 80% (Yairi, '05, Kidd '84)

      • 66% according to JSHD '91 •

• Know family hx is important •

• There is a high concordance (60-70%) of stuttering in identical twins compared to fraternal (Andrews et al 1991)

Genetic Link

• Mutations of genes in chromosome 12 and 18

• Linked 5 genes to stuttering

Congenital/Trauma Studies

• Study done by West, Nelson and Berry (1939) - 85/100 no family hx however reported congenital factors (infectious disease, diseases of nervous system, injuries)

• Poulos and Webster, 1991 – 57/169 no family hx. 37% of those reported a significant childhood event (anoxia at birth, premature birth, head injury, experiencing intense fear.)

Brain Structure Differences in PWS

• Both old and new studies have shown that some individuals who stutter have greater activity in R frontal hemisphere vs L (reversed in typically fluent speakers)

  • 1970s/1980s used EEG to look at cerebral blood flow (CBF)

  • 1995 studies looked at CBF utilizing PET confirming above findings

• 2 explanations for overactivation of R hemisphere

  • R side become "wired" for speech vs left during embryonic development

  • Child initially tries to use inadequate L hemisphere, neural networks fail and its only then they activate the R side

• Overactivation in Midbrain - found some structures of the basal ganglia show to be overactive

• Underactivity in Speech Motor Areas

• Underactivity in Auditory Areas - lack of activity in superior temporal lobe and auditory association areas and Wernickes areas

• Whole brain connectivity deficits – deficits found in neural connections involving attention, motor performance, perception and emotion

• Structural deficits in L hemisphere that may be involved with programming speech movt's

Brain Function Differences: Neurochemical Link

• There is an excess of the neurotransmitter Dopamine

• Dopamine antagonist medications have been effective in the treatment of stuttering ex: risperidone

• 3 Main influences

  • Genetics, Abnormal development of basal ganglia and/or white matter tracts, & Autoimmune Component (PANDAS)

Sensorimotor Factors

• Research has shown areas of the auditory cortex are under activated during stuttering

• PWS have deficits in perceiving speech and other sounds under conditions that stress auditory perceptual processing

• Reaction Time – PWS have slower reaction time with initiaing and terminating a vowel sound in response to a target, activating respiratory and articulatory movts, slower to respond to auditory and visual signals

Nonspeech Motor Control

• Research examining if stuttering is the result of general motor timing/coordination problem rather than a problem limited to speech production

• Studies have revealed PWS demonstrate increase difficulty with nonspeech tasks such as sequential finger tapping

• Results suggest PWS may have difficultly with response planning, organization and initiation of novel sequences of movement

SPEECH AND LANGUAGE DEVELOPMENTAL FACTORS

• Children’s learning of phonology, morphology, syntax and semantics may strain resources resulting in decrease fluency.

• CWS demonstrate an increase in language deficits or "dissociations" among language components compared to their fluent peers

SPEECH AND LANGUAGE DEVELOPMENT

• CWS exhibit more articulation errors or phonological processes than do their normally fluency peers

  • 30%-40 concurrence

• These children were found to be at risk for stuttering to persist

Language Factors

• Smith & Webster (2017): Reviewed multiple studies

  • Many individual differences in language ability and performance

  • Complex interactions between language and speech skills, developing rapidly during childhood.

• Increase risk for stuttering in bilingual individuals (Howell & Van Borsel 2011) - may demonstrate the strain on language resources

EMOTIONAL FACTORS – ANXIETY & AROUSAL

• Research show cognitive stress increases the number of disfluencies in PWS

• Bosshardt (2006) proposed that emotion can be one of the brains activities that create interference in the speech and language planning and production systems

• Anxiety

  • Specific relationship between anxiety and stuttering remains unclear

  • Coping skills can result in greater self acceptance and satisfaction with life for PWS

TEMPERAMENT

• CWS score higher on tests that measure the following personality traits

  • Sensitive temperament

  • Slower to adapt, high frustration, lack of persistence

  • More emotionally reactive and less able to regulate emotional responses

  • Perfectionism

DEVELOPMENTAL FACTORS

• Evidence for developmental factors = most onset of stuttering occurs when children are developing most rapidly during their preschool years

• Competition for neural resources / Neurological maturation

• Language learning and onset of stuttering

• Cognitive development – learning to think, remember, problem solve and plan may make demands on neural resources

Environmental Factors

• Evidence for environmental factors = higher incidence of stuttering during particular stresses

• Higher incidence of stuttering in more competitive cultures

• Parents – (Yairi 1997) suggested some CWS grew up with parents who were more demanding and anxious which may have had an impact

• Environmental Pressures:

  • Competing for talk time

  • Loss of listener attention

  • Listener impatience

  • Frequent interruptions

  • Hurried when speaking

  • Excited when speaking

  • Many things to say

  • Frequent questions (not well supported)

• Stressful Life Events

  • Physical/Emotional Trauma

  • Moving

  • Birth of new sibling

  • Parents separate or divorce

  • Family member is hospitalized or dies

  • Parents travel away from home often (one or both)

  • Holidays which cause change in routine, excitement or anxiety

Comorbidities

• Common comorbidities in CWS:

  • Developmental delay

  • Reading difficulties

  • ADD/ADHD

  • Behavioral Disorders

  • Diabetes

  • Asthma

  • Sickle Cell Anemia

Classical Conditioning (CC)

Learning caused by the association of a neutral stimulus that strongly provokes a response. The conditioning process will cause the formerly neutral stimulus to eventually provoke the response

Operant Conditioning

Learning caused when a behavior is immediately followed by a reward or punishment or the relief of punishment

Initial Conditioned Stimulus

stuttering disfluencies elicit negative reactions which triggers a response to stop them = CR (may play a role in physical tension)

Spread of Conditioning

Several other stimuli are present during the initial CR which may cause disfluencies in other environments

Operant Conditioning and Stuttering

• Stuttering behaviors seen in adults who stutter result from a combo of classical and operant learning

• Many have viewed stuttering as an avoidance reaction to being punished for normal disfluencies

Unlearning Stuttering(?)

• Ages 2-3.5: prevent the CS from eliciting negative emotion resulting in muscle tension

  • Done by changes in family environment, boosts child's natual fluency, reverse bad feelings, family acceptance

• Ages 3.5-6: implement more structured practice and rewards/praise

• Ages 6-12: treatment target to elicit the CS and make sure it is NOT followed by the CR (defensive or negative reaction)

• Adults and adolescents: Can provide more direct therapy, educating the individual that negative feelings and anticipatory fears are fueling their stuttering

Constitutional Theories

• Anomalies of Brain Organization

• Disorder of Timing

• Reduced Capacity for Internal Modeling

• Language Production Deficit

• Includes Covert Repair Hypothesis

• Multifactorial Dynamic Disorder

Stuttering develops as a result of a Timing Disorder

• Van Riper (1982): disruption of timing of muscle sequencing = stuttering

• Kent (1994): deficit in central timing that regulates speech production and integrates left-brain segmental and right brain supra-segmental aspects of speech production

Stuttering develops as a result of a Reduced Capacity for Internal Modeling

• Children learn to talk by hearing the sounds of their language and developing a “model” of how to move their articulators to make the sounds they just heard

• Then they use auditory feedback as they babble and talk to update their internal model as their speech mechanism matures as they grow

• Stuttering is thought to result from a weakness in using the internal model to transform the child’s plans for the sounds of a word into motor commands leading to speech movts

Stuttering as Reduced Capacity for Internal modeling

• Only attempts to account for core behaviors

• Explains why decrease rate of speech can result in increased fluency

Stuttering develops as a result of a Language Production Deficit

• Wingate (1988); Perkins, Kent, and Curlee (1991); and Kolk and Postma (1997) suggested stuttering results from deficits in planning and assembling the units for language production

• Language production is monitored internally

• If problem in phoneme plan is in error, production halts

• Repetitions, prolongations, and blocks can all be explained by different responses to an error

Kolk & Postma's Covert Repair Hypothesis

• Disfluencies arise bc speakers attempt to repair internally before starting to speak.

• PWS are particularly disfluent bc their phonological encoding abilities are impaired.

  • They make (and covertly repair) many phonological encoding error

  • Repetitions = repairs at end of word

  • Prolongations = repairs in middle of word

  • Blocks = repairs in beginning of word

• Analogy

  • Analogy to putting together the components of language production

  • Quality control inside the shop = internal monitoring

  • Quality control outside = auditory feedback

  • If internal model detects an error in phonetic planning, results in halting of speech (same as if there was a problem in the bike, halts production)

  • Stuttering results if internal checkpoint detects error, and speaker retries, prolongs, or pushes ahead despite error

hypothesis of a language production deficits in stuttering Physcolinguistic Approach

• A dyssynchrony between 2 components of language production ◦ paralinguistic (right side) ◦ linguistic (left side) resulting in disfluencies

• Proposes the difference between normal disfluencies and stuttering is that PWS feel pressure to continue to speak even if the dyssynchrony is detected (push forward) as well as a sense of loss of control (decrease awareness)

Stuttering develops as a result of a Multifactorial Dynamic Disorder

• Smith –believes stuttering is mainly caused by a motor speech disorder that is then influenced by cognitive, linguistic and psychosocial factors.

• Viewed as “dynamic” bcthe disfluencies are the outward manifestations of an underlying, ever changing inner situation

Multifactorial Dynamic Disorder

• suggest there is no one cause of stuttering, but an array of factors contributing to it

• The problem is to find the relevant factors and discover how they interact

Diagnosogenic Theory

• Johnson thought stuttering is cause by children who were misdiagnosed by their parents or other listeners when demonstrating typical disfluencies which resulted in tension/avoidance and then increase hesitation

• Johnsons stated: "The problem is not with the child's mouth but in the parent's ears.“

• Widely accepted theory throughout 1940s/50s

• Pinpointed environmental factors as the sole cause of stuttering, blame parent's negative reactions

Communication Failure and Anticipatory Struggle

• Oliver Bloodstein(1987; 1997) proposed that in many cases, stuttering begins when a child finds talking difficult, experiencing frustration and failure

• Anticipated difficulty in talking produces tension resulting in fragmented speech

• This leads to more frustration and failure in communication, which increases anticipation of difficulty

Capacities and Demands View

• Stuttering may emerge when child’s capacities for fluency are overwhelmed by demands

• Examples

  • Capacities : Child’s ability to plan and program for language while making fast, coordinated movements for speech ◦

  • Demands : Some children’s advanced conceptual and linguistic abilities; models of rapid and complex speech and language in environment; emotional stress on child from environment

  • treatment based on reducing demands and, when possible, increasing capacities

Joseph Sheehan

• "A child's who has begun to stutter is probably a child who has too many demands placed on him while receiving too little support." ◦

• Believed stuttering is a result of learned behavior

• Viewed stuttering as the result of a conflict between opposing drives to speak (approach) and to hold back from speaking (avoidance).

• “Don’t avoid, don’t’ hide, don’t deny your stuttering. The only way you’ll ever get over your fear of stuttering and thus become genuinely fluent; is to meet it head-on. Always do the thing you fear, and gradually you will learn not to fear it.”

Integrated Perspective

• Two Stage Model of Stuttering-Stuttering may often develop in two stages

  • Primary stage is simpler disfluencies that are the result of how the brain handles speech and language production

  • Secondary stage is a more complex pattern that is the result of the child’s and environment’s reaction to disfluencies

First Stage Primary Stuttering

• Based on PWS have differences in the way their brains process sensory information and produce motor output (auditory motor processing)

• Caused by a genetic inheritance or early brain damage

How does this inefficiency lead to Primary Stuttering?

• Many existing theories suggest dyssynchrony, at some level, is responsible for repetitions, prolongations, or blocks

• Therefore Primary stuttering may be the result of a decrease in organization of speech and language networks in the brain, which can resolve via maturation or reorganization

Perspectives on Secondary Stuttering

• Instead of saying the secondary behaviors observed are a result of the core behaviors, Guitar believes a child's temperament and "in the moment" responses and interaction with learning can result in secondary behaviors.

• These reactions may constitute the components of secondary stuttering (i.e., increased tension, escape, and avoidance)

• Because a reactive temperament causes emotional arousal, events that caused the emotion will be more deeply learned (learning is enhanced by emotion)

• Children who react to primary stuttering with increased tension, escape, and avoidance behaviors will be more likely to continue these secondary behaviors long term

• Behaviors associated with high emotion are likely to be retained permanently

• Therefore, treatment of those with secondary stuttering may be most effective if coping skills are taught, e.g. gentle onsets, slow rate, light contacts

Possibly two predispositions for Stuttering?

• Primary and secondary stuttering may have two predispositions.

• Primary most common: stuttering that is resolved through neural maturation and reorganization

• Secondary : a predisposition for a reactive temperament

How's Child's Development interact with Two Predispositions – 3 ways

• 1. Interaction with speech and language development ◦ Child with primary stuttering may be able to recover if speech and language demands are low or language ability is strong

  • Another child with primary stuttering may not recover so easily if language development demands are high or child is not strong in speech and language

• 2. Interaction with brain maturation

  • Some individuals will recover early because they have greater neural plasticity

  • Females appear to have greater organizational plasticity and more widely distributed language centers

• 3. Interactions with social-emotional development

  • As social-emotional development creates stress on children, those with higher temperaments may be more likely to have more negative reactions to difficulty with speech

Interactions with Environmental Factors

• Primary Stuttering

  • An environment that is slow-paced and accepting may be more likely to give children freedom to develop fluency at their own pace

  • An environment that is fast-paced and demanding may be more likely to delay recovery

• Secondary Stuttering

  • •Families can help reactive child develop skills to manage stress, thus decreasing likelihood of stuttering becoming persistent

  • Some life events (e.g., divorce, hospitalization) can increase vulnerable children’s reactivity, thus increasing likelihood of stuttering becoming persistent

Treatment Pre-K

• Lots of modeling, slower speaking rate (including pauses)

• Reduce environmental stresses/pressure

• Goal is to avoid negative reaction – work with caregivers on accepting the repetitions

Treatment - School Age

• Assess the amount of tension present

• Assess escape/avoidance behaviors

• If present, reduce fear

• Practice fluent speech to develop confidence (great focus if secondary behaviors are not present)

Treatment - Adolescents and Adults

• Need to first work on diminishing their defensive reactions that trigger tension and secondary behaviors.

• Need to bring awareness of the learned behaviors

• Need to reinforce most listeners are patient not rejecting

• Acceptance is key here! Building a trust is key

Client Needs

• Need to try to look at each client with fresh eyes

  • Don't make promises

  • Can't resolve things in 1 session

  • Need to know client's goals

  • Need to know how the client views their stuttering

  • how they want to talk about it/phrasing

  • Need to build rapport/trust with client and family

Insurance Considerations & Privacy Rights

• Clients need to look into what services are covered by their insurance (unfortunately, may impact your treatment)

• Need to know HIPAA Laws

• Need to know what circumstances require you to break confidentiality

Assessing Stuttering Behavior

• Mode of measurement needs to be reliable: Intra-raterreliabiltyand Inter-rater reliability \

• Speech samples –good idea to get one in tx, one in home environment. Want it to be around 300 syllables of conversational speech, 200 syllable for reading sample

• Frequency –how often does the individual stutter in speech/reading. Provides info on stuttering level

• Types of disfluencies

• Duration –longer stuttering are worse then shorter ones

• Looking at secondary behaviors

• Assessing Severity: SSI-4 most commonly used

Stuttering Severity Instrument (SSI-4)

• Assessing surface/overt features:

  • More than one sample of spontaneous speech

  • Overall score is based on sum of 3 components:

    • % syllables stuttered in readingand conversation

    • Duration of 3 longest blocks (Mean duration)

    • Physical Behaviors

    • Standardized severity rating for children and adults

Assessing Severity

• Test of Childhood Stuttering (TOCS)

• Scale of Rating Severity of Stuttering (less reliable)

• Lidcombe Program's Severity Rating Scale (good to use outside of treatment)

• Speaking and Reading Rate –can be calculated by counting syllables or words per minute. Also part of SSI-4

• Fluency Bank

• Stuttering Prediction Instrument ages 3-8

Assessing Feelings: Pre-k age

• The KiddyCAT consists of 12 yes/no questions. Only use if the client is aware of their stuttering

• The Impact of Stuttering on Preschoolers and Parents Survey–20 questions, used to determine if treatment is appropriate (example figure 8.6)

• The Behavioral Style Questionnaire –used to assess temperament

• Short Behavioral Inhibition Scale –7 point scale to measure sensitive temperament via parent report

Assessing Feelings: School Age

• A-19 Scale: Needs further research but good tool to start a discussion

• Communication Attitude Test: well researched for reliability, can determine negative feelings for children 6 and older

• Overall Assessment of the Speaker's Experience of Stuttering (OASES): assess impact stuttering has on the client's day to day life, helpful for treatment planning

• Teacher's Assessment of Student Communicative Competence (TASCC):Questionnaire filled out by teachers to reflect students' communication in classroom

Assessing Feelings: Adolescents and Adults

• Attitudes (S-24): Reliable questionnaire that can be completed for testing and re-testing attitudes

• Stutterer's Self-Rating of Reactions to Speech Situations (SSRSS): Questionnaire that assesses frequency of stuttering during various situations

• Perceptions of Stuttering Inventory (PSI): Questionnaire that assesses client's perception, may be helpful in determining awareness

• Locus of Control: Scale used by clinicians to estimate how much control the client has on their stuttering

Preschool Assessment

• Parent/child interaction observation

• Parent interview

• Obtain speech sample

• Need to obtain child's awareness/feelings

• Keep eye out for any other language/behavioral concerns

Comprehensive Assessment

• 1 . Background information– case history, informal observation, tapes from home

• 2 . Interviews: client, parent, teacher, key individuals

• 3. Observation of speech behaviors– characteristics of stuttering, related behaviors

• 4. Assessment of other speech, language, hearing

• 5. Surveys

• 6. Present of feelings and attitudes results:

  • 1. No treatment warranted

  • 2. Watchful waiting with regular family contact

  • 3. Clinician-guided environmental change

  • 4. Clinician-guided parent or caregiver delivered tx

Diagnosis - Typical

• The following assessed would determine a _______ disfluency:

  • <10 disfluencies per 100 syllables

  • Disfluencies mostly consist of multisyllabic word/phrase reps, revisions and interjections

  • Repetition units are 2 or fewer

  • The ratio of stutter like and total disfluencies will be <50%

  • All disfluencies are relaxed

Diagnosis - Borderline

• Have >10 disfluencies per 100 syllables (still are relaxed though)

• May see more syllable reps and/or prolongations

• Ratio for stutter like disfluencies is greater than 50%

Diagnosis - Beginning

• Usually will see in older pre-k age

• Observation of tension

• Increase in prolongations

• Avoidance behaviors may be present

Recommendations for Typical Fluency

• Focus on family concerns vs child's disfluencies

• Educate them on typical disfluencies

• Provide them the assessment results to back up your conclusions

• Provide them reasons for re-consult

Recommendations for Children with Borderline or Beginning Stuttering

• Enhance fluency, decide if an indirect or direct approach is the best

• Decrease/eliminate defensive responses to stuttering

• Implement Severity Rating Scale for parents to complete at home daily.

• Provide educational materials about stuttering + Getting parents involved is key!

Factors that are associated with recovery without tx

• 1. Decrease in stuttering-like disfluencies during the 12mos after onset

• 2. Female gender

• 3. No family hx or relatives that have successfully recovered

• 4. Good language and articulation skills

• 5. Good nonverbal intelligence scores

• 6. Outgoing, carefree temperament

Assessment School Age & Speech sample

• Assessment

  • Similar to pre-k but now need to involve school

  • Still need to assess frequency, type of disfluencies, secondary behaviors

  • In addition to the parent interview, need to complete teacher interview

  • Classroom observation

  • Need to assess artic and language skills?

• Speech Sample

  • Obtain conversational sample (optimally 300-400 syllables)

  • Obtain a reading sample (can you SSI-4 passage)

  • Need to assess pattern of disfluencies, severity, speech rate

Recommendations School Age

• May consider trial therapy– It may not be clear if a child at this age is truly demonstrating stuttering or just a high level of typical disfluencies

• Depending on severity and impact stuttering has on child's learning, may start with in-classroom tx, then needed "pullout" tx

• Depending on client's awareness, you may want to address negative feelings/tension

Adolescent/Adult Assessment & Recommendations

• Assessment

  • Questionnaire now includes attitude/avoidance questions (can mail out the OASES)

  • Interview – can be more direct, ask about past tx and the client's perception of their speech

  • Speech sample; conversational and reading

  • Informally assess receptive language, articulation and voice

  • Screen hearing

• Recommendations

  • Need to determine stuttering level

  • Again, important to determine cause

  • It is important for these individuals to complete self therapy

  • Important to work on tx plan together

  • May need to bargain with the client if hesitant ("let's try 4 sessions, and then you can decide if you want to continue")

  • May rec trial therapy to assess their response on various treatment techniques

  • At this stage, tx can focus on having the client modify (play around) with their stutter

  • Important to address feelings/attitudes– How they feel as an individual who stutters– How they feel prior, during and after they stutter

After Initial Eval

• Same for all levels

  • Discuss initial impressions

  • Educate on possible causes for disfluencies

  • Probable tx interventions

  • Give environmental/home recs

  • Meet informally with parents/caregivers weekly

Impact of Clinician and Clinician Views

• Impact

  • Empathy

  • Warmth – makes client feel accepted, liked, nurtured.

  • Genuineness

  • Evidence-based practice

  • Continuing education

  • Creativity and Critical thinking

• Views

  • What you believe the etiology is will shape your treatment.

  • Need to still make sure you are backing up your treatments with EBP and/or solid rationale

  • Your beliefs as a clinician may also shape the way you educate the parents/caregivers

Treatment Goals/Potential Goals

• Important to ask;

  • What does this client need?

  • What does this client need from ME?

  • What is the most important thing to address?

  • What are some barriers of progress?

• Goals:

  • Reduce frequency of stuttering

  • Reduce secondary behaviors (eye blinks, tension, head nods, avoidance behaviors)

  • Reduce negative feelings

  • Reduce avoidance

  • Create fluency-facilitating environment

  • Improve overall communication skills

Stuttering Modification

• Stuttering modification strategies = involves working directly with the precise stutter, identify it and work on muscle relaxation during the actual stutter and decrease reaction

  • Ie: pull-outs, re-dos (we will discuss all of them in details when we get to treatment)

• Purpose:

  • To increase awareness of physical tension

  • Reduce physical tension

  • Reduce struggling behaviors/unlearn secondary behaviors

  • Reduce negative reactions of the speaker Increase feelings of self-control

  • Increase awareness of speech that is disfluent

  • Approach stuttering in a relaxed approach

  • Reduce feelings of sensitive about disfluencies

  • Increase feelings of openness and acceptance

  • Reduced negative reactions to stuttering

Fluency Shaping

• Fluency Shaping (enhancing) Techniques = involves changing the way the client speaks by tweaking rate, breathing, articulation. Does not address feelings or secondary behaviors, do not bring attention to specific stutters

  • breathing techniques, light articulatory contact

• Purpose:

  • Obtain fluent speech outside of stuttering behaviors, or before stuttering events.

  • Prevent the intensity or frequency of stuttering behavior.

  • Allow for success in achieving fluency to increase confidence, decrease negative reactions to stuttering by promoting fluent speech.

  • Alter speakers’ articulation, speech rate, breath patterns, voice productions and other aspects of communication to reduce vulnerabilities to disfluencies.

Reduce Frequency

• Operant treatment– positive reinforcement for fluency or tactfully calling attention to stuttering to allow "do-overs"

  • Positive reinforcement: verbal praise, tangible prizes, rewards when child produces fluent speech

• Fluency shaping techniques– Find a level and/or method that results in fluent speech and then advance

Reduce Secondary Behaviors

• Based on belief that secondary behaviors are fueled by negative feelings that result in increased tension/fear and then rewarded bc person pushes through tension to produce word.

• Implement stuttering modification strategies that directly address the precise stutter and associated negative feeling

• Reduce negative emotions by:

  • Objectively studying it with client

  • Desensitizing the frustration and embarrassment

  • Implementing stuttering modification strategy; cancellations/redos, pull-outs,

Reduce Negative Feelings

Use cognitive behavioral therapy – helping clients think and feel more positively about their speech, listeners and diving into the environments/situations that elicit negative emotions

Reduce Avoidance

• Because of temperament, learned behavior or both the avoidance may be "hard-wired" in

• Usually see with intermediate/advanced stuttering

• Start by addressing negative emotions, fears, perceived listener reactions – client needs to learn new responses to old stimuli

Create Fluency Facilitating Environment

• Tweaking an environment might be the only thing needed with borderline stuttering

  • Have parents speak at slower rate, frequent pauses, increase 1:1 attention

• For school-age children, important to involve the classroom.

• For adults, important for them to create a supportive environment, get loved ones involved

Fluency Shaping (enhancing) Techniques

• involves changing the way the client speaks by tweaking rate, breathing, articulation. Does not address feelings or secondary behaviors, do not bring attention to specific stutters

• Purpose

  • Obtain fluent speech outside of stuttering behaviors, or before stuttering events.

  • Prevent the intensity or frequency of stuttering behavior.

  • Allow for success in achieving fluency to increase confidence, decrease negative reactions to stuttering by promoting fluent speech.

  • Alter speakers’ articulation, speech rate, breath patterns, voice productions and other aspects of communication to reduce vulnerabilities to disfluencies

Fluency Enhancing Techniques

• Light Contact: Producing plosive sounds more gently/decrease tension

• Easy onset: Producing non-plosive sounds more easily

• Slower speech rate/stretched speech: Slow down rate of speech or prolong speech sounds in a general capacity

• Relaxed breath: Work on coordinating respiration with phonation. Understanding deep breaths vs shallow vs full breaths

• Pausing: Identifying/creating natual breaths allowing for pausing

Stuttering Modification Strategies

• involves working directly with the precise stutter, identify it and work on muscle relaxation during the actual stutter and decrease reaction

• Purpose

  • To increase awareness of physical tension

  • Reduce physical tension

  • Reduce struggling behaviors/unlearn secondary behaviors

  • Reduce negative reactions of the speaker Increase feelings of self-control

  • Increase awareness of speech that is disfluent

  • Approach stuttering in a relaxed approach

  • Reduce feelings of sensitive about disfluencies

  • Increase feelings of openness and acceptance

  • Reduced negative reactions to stuttering

Stuttering Modification Strategies

• Pull-outs/sliding: stretching of the actual stuttering moment. (ie: sssssslide)

• Bouncing: Produce words with more ease. Increase awareness of where tension is (ie: Ball = B B B Ball)

• Cancellation/re-do: Produce word again after stutter with less tension and at a slower rate, more controlled (ie: "I w w w want (want) to go)

• Catching the stutter: Only to use during tx. Have client identify tension/stuttering moments by signaling to increase awareness.

• Intentional stuttering: Used to reduce anxiety, increase sense of control

Borderline? Potential Goals

• Reduce frequency of stuttering

• Reduce secondary behaviors (eye blinks, tension, head nods, avoidance behaviors)

• Reduce negative feelings

• Reduce avoidance

• Create fluency-facilitating environment

• Improve overall communication skills

Reduce Frequency

• Operant treatment – positive reinforcement for fluency or tactfully calling attention to stuttering to allow "do-overs"

  • Positive reinforcement: verbal praise, tangible prizes, rewards when child produces fluent speech

• Fluency shaping techniques

  • Find a level and/or method that results in fluent speech and then advance

Create Fluency Facilitating Environment

• Tweaking an environment might be the only thing needed with borderline stuttering

  • Have parents speak at slower rate, frequent pauses, increase 1:1 attention

• For school-age children, important to involve the classroom.

• For adults, important for them to create a supportive environment, get loved ones involved

Education

• Educating the parents/ family is so important

  • Can provide them video/book/website recs

  • Write down specific modeling techniques

  • Brainstorm together how to facilitate fluency in their home environment

Educate and then Collaborate! Partnership with Parents

• Begin by identifying factors which disrupt fluency

  • Child Related vs environmental

• And then educate & collaborate:

  • Listen and Learn; Communicate openly

  • Share decision making

  • Respect parent’s choices/opinions