Fluency disorders

types of fluency disorders

developmental stuttering, neurogenic acquired stuttering, psychogenic acquired stuttering, cluttering

fluent

able to express oneself readily & effortlessly- exchanging ideas with little to no effort

stuttering

an involuntary disorder of fluency that interferes with the forward flow of speech

components of stuttering

core behaviors, secondary behaviors, feelings & attitudes

core behaviors

repetitions, prolongations, blocks

secondary behaviors

learned behaviors to escape/avoid stuttering

feelings & attitudes

feelings & stress with stuttering make the stuttering make the stuttering worse

dysfluencies/stuttering/stammering

Refer to events that contain monosyllablic whole-word repetitions, part-word repetitions, audible sound prolongations, or silent fixations or blockages

stuttering facts

Stuttering occurs in all cultures & languages (signif variability)

Stuttering occurs in all occupations, intelligence, & income groups (signif variability)

Cause of stuttering =70% genetic & 30% environment

Onset: 2-5 years of age (95% before the age of 4; average 33 months)

Hard to tell between normal disfluency & abnormal

Prevalence: 1%

Incidence: 5% (4% outgrow, 1% continues through life)

Spontaneous recovery 88%-91%

Male to female: 4:1 in long run

More females experience spontaneous recovery

repititions

include part-word/word/phrase

prolongations

Sound or airflow continues, but articulatory movement is stopped

As short as ½ second may be perceived as abnormal by the listener

blocks

Inappropriate stoppage of airflow or voicing; movement of articulators may be stopped

May occur at any level- respiratory, laryngeal, or articulatory

May be accompanied by tremors of lips, tongue, jaw, or laryngeal muscles

Last about 1 second

unconscious actions

Respiratory = can't breathe

Laryngeal = vocal cords shut

Articulatory = sound stays there

additional speech behaviors observed

dysrhythmic phonations, interjections, revisions, abnormal speaking rate, changes in pitch/volume, abnormalities in respiration, changes in phonation, changes in articulatory production

things that make up feelings & attitudes of fluency

embarrassment & frustration, strength of feelings increases with more stuttering episodes experienced, fear & shame, feelings becoming more perminent

what are secondary behaviors

learned behaviors that are triggered by the experience of stuttering or the anticipation of it

types of secondary behaviors

Escape: behaviors used when the speaker is stuttering & tries to terminate the stuttering & tries

Avoidance: behaviors that occur when the speaker anticipates a stuttering event and tries to avoid it

commonly observed behaviors

Eye blinking, facial grimacing, tapping, snapping, head jerking, quivering of nostrils, larger motor movement, poor eye contact

non-physical secondary behaviors

interjections, circumlocution, alteration of words, avoidance of situations

factors increasing the likelihood of persistent stuttering

Relative who has persistent stuttering

Being male

Onset after 3.5

No reduction in symptoms during first year (with/without treatment)

Persistence of symptoms beyond year 1

Multiple repetitions 3+

Presence of prolongations & blocks beyond year 1

Reduced phonological skills

factors associated with recovery

being right handed, having slower speech rate & more mature motor system, having a mother that uses simpler language when talking to children, more developed/mature white matter tracks in the brain, longer duration of breastfeeding

Being right handed, having a non-directive female caregiver

When showing signs of disfluency, more easy to alter environment to create less stress on child

Having a slower speech rate & more mature motor system

Gives individual more time to not get stuck on communication, asynchrony with more/less mature motor system, allow child time to communicate

Having a mother that uses simpler language when talking to children

More mature language=good vocab, but not as comfortable

More developed/mature white matter tracts in the brain

Grey matter= Wernicke's/broca

White matter= signals from one end to another end smoothly, if not, speed of processing gets messed up-> changes in chemical reactions in neurons

facts about cluttering

much more limited, age of onset similar to stuttering, age at identification & treatment later than stuttering

core behaviors of cluttering

atypical pausing in sentences, not expected syntactically, deletion/collapsing of syllables, excessive typical disfluencies, maze behaviors, deletion of word endings, cluttering affects phonological/language

school setting overview of stuttering

Referral (teacher, parent, screening)- date stamp

Schedule evaluation plan with teacher, parent

Evaluation Plan meeting

Gather case history form, first permission, follow-up letter & second permission

Evaluation

Standardized assessment, 300 syllable sample, structured observation, teacher severity rating, parent severity rating, impact on academics, complete report mail to parents

Eligibility meeting to determine if child meets states criteria (agreement from all 3 parties)

IEP meeting: goals for 1 year, permission, follow-up letter

clinic/hospital setting overview of stuttering

First session

Interview parent, evaluate fluency, discuss diagnosis & severity, discuss therapy plan

fluency modification

fluency modification works directly on stuttering, increase awareness of stuttered speech, examine & reduce physical tension, ultimately change moments of stuttering, designed to manage & discuss emotion

fluency shaping

alter students' breathing, speech rate, voice production, & articulation in ways that facilitate fluent speech. Relaxed breath, slow stretched speech, smooth movement, easy voice, light contact, stretched speech

natural history of developmental stuttering (created by guitar)

Typical dysfluencies (2-6 years): low number of dysfluencies, part-word or single syllable prolongations, possible sound prolongations & tense pauses, revisions more frequent over time

Borderline stuttering (2.5-3.5 years): high number of dysfluencies, multiple syllable repetitions. Secondary behaviors are rare

Beginning stuttering (3.5-6 years): rapid, multiple repetitions with tension, blocks, difficulty initiating words.

Secondary behaviors: escape & frustration

Absolutely see for therapy

Intermediate stuttering (6-13): blocks, repetitions, prolongations

Secondary behaviors: escape (to terminate blocks), avoidance behaviors <- shows this is intermediate stuttering

Advanced stuttering (>13): long, tense blocks, repetitions, prolongations, lip/jaw tremors.

Secondary behaviors: sophisticated escape & avoidance behaviors

normal disfluency (2-6 years)

Part-word repetition, single-syllable word repetition, multisyllabic word repetition, phrase repetition, interjection, revision-incomplete phrase, prolongation, tense pause

borderline stuttering

More than 6-10 disfluencies per 100 words

Often more than two units in repetition

More repetitions and prolongations than revisions or incomplete phrases

Disfluencies are loose & relaxed

Rare for child to react to disfluencies

Concerned for child

indirect treatment for borderline stuttering

Educate parent on changes that would reduce communicative stress & issues that exacerbate problem

Discuss all, but address 1-2 problems at a time

Model & invite participation

Follow-up sessions (have family discuss)

Praise success

Refer when necessary

direct treatment for borderline stuttering

Focus on fluency shaping (therapist & parent(

Praise fluency (not too much)

Ignore dysfluency

Have parents log fluency with rating scale

With progress, reduce positive reinforcement schedule

Focus on confidence

Model easy stutters

Play with fluency to increase child's comfort level

Voluntary stuttering

beginning stuttering

Signs of muscle tension & hurry appear in stuttering. Repetitions are rapid & irregular

Pitch rise may be present toward the end of a repetition or prolongation

Fixed articulatory postures

Escape behaviors sometimes present (eye blinks, head nods, um)

Awareness of difficulty & feelings of frustration are present, but no strong negative feelings about self as speaker

treatment for beginning stuttering

First visit is same as borderline

Follow-up visits (assess stuttering, discuss progress, introduce new techniques procedures as necessary)

Techniques

Continue fluency shaping, daily practice sessions, unstructured treatment conversations, maintenance period

school-age children

Frequent core behaviors (blocks, repetitions, prolongations)

Child uses escape behaviors to terminate blocks

Child appears to anticipate blocks, often using avoidance behaviors prior to feared words

Fear before stuttering

treatment of intermediate stutters

fluency modification & shaping

advanced stuttering

The stuttering is not going away, but it may get more mild

Need support from family

Core behaviors: longer/tense blocks with tremors of lips, tongue, or jaw, repetitions & prolongations

Stuttering may be suppressed in some individuals through avoidance behaviors

Complex patterns of avoidance & escape behaviors characterize the stutterer

Emotions of fear, embarrassment, & shame are very strong

treatment of severe stuttering in adolescents & adults

spontaneous/controlled/acceptable fluency, therapy sessions, increasing approaching behaviors, maintenance, fluency shaping

pharmacological approaches

tranquilizers/sedatives

- Focuses on muscle tension & emotional state

Haloperidol

- Diminishes uptake of dopamine, but has major side effects

Olanzapine (dopamine antagonist)

- Limited research

assistive devices

masking devices: white noise in your ears so you don't hear your own speech

delayed auditory feedback: not hearing yourself for the first time, so it would come through in the ears delayed

evidence-based management

Most effective treatments for children: therapies with response- contingent principles

- They produce utterance & give feedback

- Praise fluency/ignore disfluency

Most effective treatment for adults (speech, social, emotional, cognitive outcomes)

- Ability to understand/explain disorder

-Variants of prolonged speech

-Response-contingencies

-Infrastructure variables

general recommendations

Preschoolers:

- Response-contingent

Older school age

-Response-contingent, fluency shaping, daily practice

Young adult

-Regulated breathing or prolonged speech

Adults

-Prolonged speech

-Intensive intervention: taking out of normal environment for 2 weeks into therapy

-Group work: able to support each other (depends on level of disorder)

-Planned transfer of skills (from theory room to normal environment)

-Maintain naturalness of speech

-Look for other systematic reviews

-Statistic formulas, research articles

cluttering

a fluency disorder characterized by a rapid and/or irregular speech rate, excessive difluences, & other symptoms like language or phonological errors

diagnosis & evaluation of cluttering

case history & interview

direct assessment

- fluency assessment (speech sample)

- language assessment

- assessment of cluttering characteristics

- assessment of co-existing disorders

treatment approaches

rate control (slow down)

address linguistic skills & language weaknesses

- narrative organization, turn taking, topic maintenance, listening skills, use of more complex syntax

fluency-inducing activities

focus on fluency success from a linguistic hierarcy

address speech issues

malingering

Deliberate faking of a physical or psychological disorder motivated by gain.