COMD Exam 3

Stuttering

characterized by stops, starts and hesitations in the speech

Fluency

characterizes the flow of speech during communication - the consistent ability to move the speech production apparatus in an effortless, smooth, rapid manner resulting in continuous uninterrupted forward flow of speech

Disfluency

a speech behavior that disrupts the fluent forward flow of speech, such as pauses, interjections and revisions

Fluency disorder

speech with an unusually high rate of stoppages that disrupt the flow of communication and are inappropriate for the speaker's age, culture, and linguistic background

Characteristics of fluency disorder

sound and syllable repetitions
sound prolongations
interjections
words broken by pauses
blocks
word substitutions
excess physical tension

Fluency disorder contains the presence of...

1) disturbance in normal fluency and timing patterns

2) disturbance in social communication, academic performance, or occupational achievement

Core features of fluency

primary characteristics - repetition, prolongation, block (stoppage of movement and airflow)

Secondary features of fluency

result from excessive mental and physical efforts to promote fluent speech to disrupt disfluent speech

Examples of secondary features

eye blinks, lip tremors, head jerks, fillers, pauses, stomping, word changes, finger tapping, negative feelings/attitudes, clicking tongue, clenching jaw, wrinkling nose, clenching hands, bunching shoulders, crossing legs

Avoidance behaviors

word and sound avoidance
circumlocution
postponement
situation avoidance

Sound avoidance

person changes the sound or word that they know will likely be stuttered

Circumlocution

"uh" in between phrases

"we went to the uh.. the uh... the uh.. city today"

Revision

"um" in between phrases and rephrasing the phrase in different way

Phase repetition

"I want, I want, I want.... ice cream"

Sound repetition

"m.. m... mine"

Whole word repetition

"daddy... daddy.. has ice cream; I want.. want... want... more milk"

Prolongation

continued airflow, but the articulations remain in place

"I wwwwwwant more cake"

Block

"I... (pause) want more cake"

Broken word

when a pause or prolongation is in the middle of the word

"My name is syd(pause)ney"

Syllable repetition

"a big an-an-animal"

Are all disfluencies stuttering?

no

Normal disfluencies

age 2 - whole word repetitions, interjections and syllable repetitions

age 3 - revisions are common

lifelong - revision, repeat phrases, interjections, repeating multisyllabic words

Within-word disfluencies

sound/syllable repetitions, sound prolongations, blocks

Between word disfluencies

normal unless they occur at a high rate - phrase repetitions, interjections and revisions

Predisposing factors of disfluency

family history

gender - male are more likely

brain morphology and neural
physiology (less asymmetry)

motor speech coordination - rate of speech exceeds capacity to produce fluent speech

Precipitating factors

age

developmental stressors - interpersonal and communicative

self awareness

75% of developmental stuttering will resolve by

age 4

Developmental stuttering

most common type beginning in preschool years, gradual onset with increasing severity occurring with content words and syllables

Neurogenic stuttering

associated with neurological disease or trauma, occurring on function words through utterance, no secondary characteristics, no improvement with repeated readings/singing

Developmental framework phases

phase 1 (2-6 years) - sound/syllable repetitions

phase 2 (elementary) - stuttering on content words, aware of situation

phase 3 (8 years - young adult) - stuttering in response to situations, fear/frustration

phase 4 - advanced, fearful anticipation, avoidance of words and situations, embarrassment

Fluency assessment

case history, interview, observation, standardized testing, stuttering severity index

Purpose of fluency assessment

determine risk of stuttering, determine other communicative risk factors/disabilities, determine when therapy is needed and which therapy approach is beneficial

Identification of fluency disorder

complicated by the fact that nearly all persons are disfluent in their speech at least some of the time

calculate - number of disfluences on average per 100 words, number of disfluencies on average per 100 syllables

Diagnosis of fluency disorder

more likely to be diagnosed when...

- 10 or more disfluencies per 100 words

- 3 or more stuttering like disfluencies per 100 words

- secondary behaviors

Indirect treatment approach

milk for children beginning to stutter, slow, relaxed speech model with play

Direct treatment approach

only for children stuttering at least a year; moderate - severe

modify speech, increase easy speech and change from hard to easy speech

Environmental modification

avoid putting them on the spot
repeat to show listening
make comments
don't ask questions
modify stressful activities
easy talking

Operant training

identify disfluencies
prompt fluent speech
prompt self-corrections

Treatment for older adults

fluency shaping - reduce speech rate, reduce rate and tension, lengthen naturally occurring pause, add more pauses, acknowledge, praise

stuttering modification - pause after a stuttering event, catch yourself during stuttering and ease out of it, use prior to anticipated stutter, slow down

Cluttering

rapid or unusual rate of speech that results in disfluencies, frequent and unusual pauses, and a blending of sounds in words; articulation errors more common

Cluttering consists of disfluencies in...

rapid speech rate, interjections, phrase repetitions, incomplete word production

AAC system

approach to treatment considers the manifestation of a disorder and how activities and participation are impacted

Four components of AAC system

symbol, aid, strategy, technique

Symbol

something that strands for something else

Aided symbol

something external to the body transmits the message

Unaided symbol

requires only the body (gestures)

Acoustic symbols

tones that mean something

Aid

type of assistive devise that is used to send or receive messages

Electronic aid

speech generating device

Non-electronic aid

use no technology or low/light technology

Assistive technology

may aid with motor performance

Strategy

the way symbols are effectively and efficiently conveyed - direct selection, indirect selection, coded access

Technique

the way in which messages are transmitted

Direct selection

physical pressure, physical contact, pointing without contact, speech/voice input

Indirect selection

scanning with single or dual switches - display selects from a row of symbols and user stops it to voice

Complex communication needs

exist when individuals cannot meet their daily communication needs through their current methods of communication

Causes of complex communication needs

- intellectual disability
- cerebral palsy
- autism
- childhood apraxia of speech
- TBI
- stroke
- degenerative disease

Purpose of communication

express needs and wants, information transfer, social closeness, social etiquette, communicating with oneself

ID of complex communication needs

parents, teachers, SLP's, PT's, OT's, rehabilitation engineers, social worker, psychologist, nurse, doctor, vocational counselor

Assessment of CCN

- barriers that exist
- what facilitates good communication
- what AAC system would enhance communication

Purpose of AAC

meeting unmet communication needs, increasing communication competence, increasing participation in society

Deglutition

normal swallowing

Dysphagia

disorder of swallowing

Penetration

food/liquid reaches the vocal folds

Aspiration

food/liquid passes the vocal folds into the airway

Phases of swallowing

oral, pharyngeal, esophageal

Dysphagia causes

developmental, neurological, strucutal

Oral-motor system

structures and neuromuscular functions of anatomy for speaking and swallowing

Oral-motor functions

strength and coordination of articulators

Oral-motor muscular tone

tension/posture of articulators

Oral-motor sensation

sensitivity of tastes, textures

Oral preparatory phase

prepares the substance to be swallowed, starting when the food/liquid enters the mouth, soft palate lowers toward tongue to contain bolus and prohibit flow of food, chewing

Oral phase

move bolus to the rear of the oral cavity for propulsion down the throat

Pharyngeal phase

propels bolus down he throat to the entrance of esophagus, starts with the anterior faucial pillars and swallow is triggered, cricopharyngeus muscle or upper esophageal sphincter is juncture between pharynx and esophagus, reflective cough is reflex

Esophageal phase

moves bolus through the esophagus into the stomach

Disordered swallow

individual exhibits unsafe or inefficient swallowing pattern that undermines the eating or drinking process - penetration and aspiration

Penetration during dysphagia

food enters larynx causing choking

Aspiration during dysphagia

food passes through the larynx into the lungs, which can cause pneumonia

Pediatric feeding disorder

persistent failure to eat adequately for a period of at least 1 month, which results in significant loss of weight or failure to gain weight

Pediatric feeding disorder characteristics

problems with oral phase, refusing certain foods, requires certain presentation of foods, rituals with eating, pain from reflux

Unsafe feeding and swallowing

results from the dysfunction of or damage to a child's oral-motor system or an inappropriate eating rate, problems with planning, timing, coordination, and sensation needed for swallow

Causes of feeding disorder

- hypotonia
- delayed motor development
- physical deformities
- down syndrome
- cerebral palsy
- cleft palate

Risk factors for feeding disorders

- prematurity
- low birth weight
- prenatal drug exposure
- PKU
- diet restricitons

ID of feeding disorders

referral within first few days of birth, monitor of height and weight, excessive feeding time, poor weight gain, rigid eating, discomfort during feeding should be monitored

Case history of feeding disorder

length of meals, quality of intake, child's progression from breast/bottle, history of formula and volume tolerated

Feeding and swallowing evaluation

evaluation of the structures and functions of the oral-motor mechanism - lips, tongue, jaw, teeth, soft palate, hard palate

Treatment of feeding disorder

ensuring adequate nutrition, alternative nutrition may be needed, improving the experience of eating

Improving feeding/swallowing

muscle tone, articulator movement, oral-motor sensitivity, body posture, coordination of swallow, chewy tubes, seating modifications

Shaping

start with the child being in the same room as food - child moves closer, smells food, touches food, tastes food, eats food

Conditioning and reinforcement

reward child for positive feeding, increase behavior to continue reward, pair undesired foods with desired foods

Systematic desensitization

food inventory is taken - liken foods are paired with disliked foods

Alternative and supplemental feedings

Are needed for those who....
- cannot meet 80% of caloric needs
- have not gained weight
- lost weight in 3 months
- weight/height ratio 5th percentile
- feeding time is greater than 5-6 hours daily

Enteral feeding tube

directs formula to stomach, placed through nose or directly into stomach

NG tube

nose to stomach

G tube

direct to stomach

J tube

directly into jejunum, small intestine

Oral prep phase in adult dysphagia

problems controlling ingested materials, difficulty biting/chewing, inefficient oral preparation, requiring increased time to prepare bolus, impaired sensitivity of tongue/lips

Oral phase in adult dysphagia

conditions experiencing problems include: strokes, progressive neurological disease, tooth loss

characteristics - inability to adequately control bolus flow, delayed initiation of bolus movement

Pharyngeal phase in adult dysphagia

occurs in neurological conditions or head/neck cancer

characteristics - delayed initiation of pharyngeal swallow, diminished tongue/pharyngeal muscle force, reduced laryngeal closure, inadequate opening of cricopharyngeus muscle

Underlying pathology of adult dysphagia

*secondary disorder*
neurological damage, laryngeal damage/trauma