Chapter 8: Fluency Disorders

• Fluency - speech that is effortless, easy, rhythmical, evenly flowing
• Disfluency - speech with phrase repetitions, interjections (fillers in speech), pauses, revisions

Fluency Disorders

• Speech disfluencies - interfere with the ability to communicate effectively and may cause the speakers to have negative emotional reactions

Stuttering

• Stuttering - high number or duration of repetitions, prolongations, and/or blockages that interrupt speech
• Stuttering is often combined with - excessive mental and physical effort to resume talking (struggle)
• Stutters may have a - Negative perception of their communication abilities, low self-esteem

Primary Stuttering

• Core behaviors of primary stuttering - repetitions, prolongations, blocks
  • Repetitions - ex. bbbbasebbball
  • Prolongations - stretch out a sound for the long period of time ex. vvvvvvan
  • Blocks - silent prolongations (car, hold tongue tightly in the /k/ positions)

Secondary Stuttering Behaviors

• Secondary stuttering behaviors - counterproductive adaptations that started out as a way to help the stutterer
  • Blink eyes, open jaw, flap arms
  • Become more automatic, less successful in escaping the stutter

Individual Variability

• Stuttering is worse when
  • Pressure
  • Content words
  • Long and complex sentences
  • Authority figures
  • Hurry
• Stutterers could become fluent when
  • Sing
  • Use pretend voices
  • Choral reading
  • Talk to babies/animals
• Severity of stuttering may change over time

Differences Between Individuals Who Do and Do Not Stutter

• Person who stutters has - more negative concepts about themselves, high levels of concerns regarding their speech
• Subtle differences in the language abilities of people who do and do not stutter
• Less efficient motor systems - may contribute to stuttering
• People who stutter use their brains a little differently during speech production
• Decreased neural fibers between the auditory processing and motor speech areas
  • Transition between Wernicke’s and Broca’s not quite working right

Myths

• Stuttering is not that result of a nervous condition
• Parent’s reaction to their child’s disfluencies do not cause stuttering

The Etiology of Stuttering

• Complex relationships between
  • internal (neurological and cognitive) factors
  • external factors
• Currently the etiology of stuttering remains unknown

The Development of Stuttering

• Early Stuttering
• Normal speech in not completely fluent
• Most pre-school children are “dysfluent”
  • Phrase repetition
  • Interjections
  • Revisions
  • Pauses
• Few kids
  • Speech disfluencies increase in %
  • Exhibit sound repetitions, prolongations, and blocks
• Stuttering-like disfluencies: 3/100 words
• Feelings of frustration

Genetic Influences

• Strong evidence for genetic influences on the development of stuttering
• Relatives of people who stutter are generally at greater risk for stuttering then relatives of people who do not stutter

Environmental Demands and the Capacity for Fluency

• Demands and Capacity Model (DCM) - disfluencies are likely to occur in children’s speech when there is an imbalance between the demands for fluency and the child’s capacity to produce fluent speech
• 4 interrelated mechanisms contribute to the capacity for fluency
  • Neural development that supports sensory-motor coordination
  • Language development
  • Conceptual development
  • Emotional development

The Influence of Learning

• When multiple experiences occur over time as might happen during repeated instances of speech disfluency
• New neural groups that are related to speech disfluency may form, grow, and strengthen
• Children may likely recognize subtle similarities in speaking context that induce more emotion and more tense disfluencies
• Anticipate difficulties, heighten muscle tension,  which increase the likelihood of disfluencies

Factors that Contribute to Chronic Stuttering

• Stuttering resolves in 65-80% of the individuals who stutter in childhood
• Growth spurt - motor speech control, language, cognition and temperament
• Chronic stuttering - used to refer to individuals who stutter into adulthood

Contributing Factors

• Genetics - natural recovery is more likely in children who do not have relatives who stutter
• Negative Feelings and Attitudes - feeling that stuttering controls the person
• Avoidance - avoid certain sounds/words/speaking situations
• Difficulties with Speech Motor Control - evidence of unusual patterns of breathing, vocalizing, and speaking even when they are not stuttering; variance of rate
• Difficulties with Language Formation - linguistic variables such as phonology, semantics, and syntax may contribute to stuttering

How to Interact with a Person Who Stutters

• Maintain reasonable eye contact
• Do not finish his words or sentences
• Do not interrupt
• Pay attention to what the person is saying, not how he is saying it
• Pause at least 1 second prior to responding
• Do not allow common stereotypes to override your opinion of the person who stutters

Assessment Procedures

• Interviews and Case Histories
  • Other family members that stutter
  • Changes in the disfluency over time?
  • Perceptions about the person’s fluency
  • Perceptions of others regarding the person’s fluency

Tests of Stuttering

• The Test of Childhood Stuttering
  • Name pictures as rapidly as possible
  • Produce sentences with complex grammar
  • Answer questions about a series of pictures
  • Tell a story that corresponds to the pictures
  • Determine if a child is stuttering (compares # and types of disfluencies to normal)
• Stuttering Severity Instrument
• Determine the severity of the stuttering
• Speech samples in reading and conversation contexts
• Speech Samples
• 100 word sample
  • Calculate
  • Total number of words
  • Count number of words that contain non-stuttering like disfluencies (phrase repetition, revisions, interjections)
  • Count number of words that contain stuttering like disfluencies (sound/word repetitions, prolongations, blocks)
• Screening - hearing, OME, voice quality
• Speech/Language Testing - receptive and expressive vocabulary/language skills, articulation
• Feelings and Attitudes - Scales that patients self-report

Treatment

• There are two types of treatment
  • Stuttering Modification - helps the stutterer change his stuttering so that it is relaxed and easy
  • Fluency Shaping - establish a fluent manner of speaking that replaces stuttering

Stuttering Modification Therapy

• “change the way he stutters”
• Charles Van Riper (1960s) - a founding father of speech pathology, specifically articulation and stuttering
• Client is taught to stutter less and more easily
• Speech is more natural
• Considerable focus on attitudes / negative reactions to speaking
• Motivation, Identification, Desensitization, Variation, Approximation, Stabilization

Stuttering Modification: Approximation

• Cancellations - stuttering is modified after a stuttered word is completed
  • taught to stop as soon as a stuttered word is completed, pause, and then say the word again in an easy manner
• Pull outs - stuttering is modified within the moment of stuttering
  • ease their way out of repetitions, prolongations, and blocks
• Preparatory Set - modify the stuttering before it occurs
  • anticipate stuttering on an upcoming words or sound and form a preparatory set in which they ease their way into the word

Fluency Shaping Therapy

• Neilson and Andrews (1992)
• Client is taught to have stutter-free speech
• Focus on speech naturalness
• Little to no attention given to attitudes/negative reactions
• Techniques involve:
  • slower rates of speech
  • relaxed breathing
  • easy initiation of sounds
  • smooth transitions between words

Integration of Stuttering Modification and Fluency Shaping Techniques

• Best to combine the 2 methods
• Therapy for children who stutter (3-8 years old)
• Most clinicians use fluency shaping approaches
• “Turtle talk” – slow easy onset
• Involve the family

Cluttering

• Cluttering - rapid bursts of dysrhythmic, unintelligible speech