Comprehensive Study Notes: Stuttering and Dysphagia

Stuttering: Introduction and Developmental Overview

Module Objectives - Focus on developmental stuttering. - Describe factors contributing to stuttering. - Describe the three components of stuttering: Core behaviors, Secondary behaviors, and Feelings and attitudes. - Describe stuttering using the WHO-ICF (International Classification of Functioning, Disability and Health) framework. - Identify basic facts about stuttering and their clinical implications.
Terminology and Definitions - Preference for Terminology: Refers to "People who stutter," "Stutterer," and "PWS" (Person Who Stutters). - Disfluency: Denotes interruptions of speech, which can be either normal or abnormal. - Distinction: Disfluency associated with developmental stuttering is distinct from disfluencies resulting from acquired brain injury or psychological trauma. - Typical Disfluency: Defined as hesitancies that are unequivocally not stuttering.
Etiology: What Causes Stuttering? - The exact causes are not fully understood and are often referred to as a "mystery." - Key Factors: - Genetics. - Developmental influences. - Environmental influences. - Precipitating Factors: Different factors acting in isolation or combination may precipitate onset in children with a neuropsychological predisposition or inborn tendency for stuttering. - Developmental and Environmental Contributions: - Genetic and congenital influences form the baseline. - Speech and language acquisition, along with other developmental influences, precipitate disfluencies. - Environmental factors such as criticism and stressful events, combined with neurodevelopmental factors, can increase severity. - Repeated embarrassment leads to negative feelings and attitudes regarding communication.
Metaphorical Descriptions of Stuttering - The Guy Who Trips You Repeatedly: Stuttering is compared to walking down a street where a random person trips you. If it happens once, it is minor. If it happens repeatedly (e.g., every ten yards), you stop enjoying the scenery, the weather, and others. You become hyper-vigilant, constantly looking for the person who will trip you. Eventually, you stop focusing on walking and put all attention on "not tripping." On some days, you may not want to walk at all. - The Iceberg Metaphor: Attributed to Dr. Joseph Sheehan. Stuttering is like an iceberg, with only a small portion visible above the water (behaviors) and a much larger, significant portion below the water (feelings and attitudes).
The Three Components of Stuttering 1. Core Behaviors: Basic speech interruptions. 2. Secondary Behaviors: Learned reactions to core behaviors. 3. Feelings and Attitudes: Emotional and cognitive responses to the experience of stuttering.
Core Behaviors in Detail - Repetitions: - Most frequent in children just beginning to stutter. - Types include sound, syllable, or single-syllable word repetitions. - Example: "li-li-li-li-like this." - Prolongations: - Typically appear later than repetitions, though they can be present at onset. - Occurs when sound or airflow continues but the movement of articulators is stopped. - Abnormal perception can begin at durations as short as $0.5\,\text{seconds}$ . - In extreme cases, they may last for several minutes. - Blocks: - Usually the last core behavior to appear, but can occur near onset. - Defined as inappropriate stoppage of airflow or voicing and movement of articulators. - Can occur at the respiratory, laryngeal, or articulatory levels. - May involve tremors of the lips, tongue, jaw, or laryngeal muscles. - Often results from physical tension and can be a learned response to fear.
Secondary Behaviors: Learned Reactions - Triggered by the experience or anticipation of stuttering. - Escape Behaviors: - Occur during a stuttering moment to terminate the stutter and finish the word. - Examples: Eye blinks, head nods, hand/foot tapping, tense lips, interjecting extra sounds. - Avoidance Behaviors: - Occur when a speaker anticipates a stutter and tries to prevent it before attempting the word. - Examples: Changing the word (word substitution), circumlocution, saying "uh," or eye blinks.
Feelings and Attitudes - Embarrassment and frustration arise from the experience. - Feelings become more severe with more stuttering experiences. - Fear and shame contribute to the severity of core and secondary behaviors. - Attitudes: Feelings that have become permanent and affect beliefs about oneself or listeners.
WHO-ICF Framework and Stuttering - Health Condition: The disorder or disease. - Contextual Factors: Include Environmental Factors and Personal Factors. - Interactions: Affect Body Functions & Structures, Activity, and Participation.
Basic Facts: Onset - Typical onset is just before $3\,\text{years}$ old, with most occurring between $2$ and $3.5\,\text{years}$ . - Older children up to $12\,\text{years}$ may also begin to stutter. - Onset patterns: Sporadic, gradual, or sudden. - Common behaviors at onset: Syllable and single-syllable word repetitions are most common. More than $2\,\text{syllable repetitions}$ per instance is a sign of stuttering (Yairi & Ambrose, 2005).
Prevalence, Incidence, and Recovery - Prevalence: - Ages $3\text{--}5\,\text{years}$ : $2.73\%$ . - Ages $12\text{--}17\,\text{years}$ : $1.43\%$ . - Incidence: Lifetime incidence is between $8\%$ and $10\%$ . - Recovery: Without professional treatment, recovery rate is above $80\%$ . - Factors Associated with Recovery: Being right-handed, having a non-directive mother who uses less complex language, having a slower speech rate, and a mature speech motor system.
Persistence and Sex Ratio - Risk Factors for Persistence: - Family history of persistent stuttering. - Gender: Boys have a higher risk; girls tend to recover more quickly (if they don't, likelihood of persistence is high). - Age of onset: Onset after $3.5\,\text{years}$ . - Frequency/Severity: Part-word reps, single-syllable reps, prolongations, and blocks not decreasing one year after onset. - Duration since onset: Beyond one year. - Duration of moment: More than three repetitions (li-li-li-li-like), rapid repetitions. - Phonological skills: Below average norms. - Sex Ratio: - At age $3$ (initial screening): $1.65:1$ . - Two years later: $2.8:1$ . - General US school children: roughly $3:1$ Ratio.
Variability and Predictability - Anticipation: Ability to predict words they will stutter on during a reading passage. - Consistency: Tendency to stutter on the same words in repeated readings. - Adaptation: Stuttering decreases over successive readings (up to $6\,\text{readings}$ ).
Linguistic Factors - Adults stutter more on: Consonants, word-initial positions, contextual speech (vs. isolated words), content words (nouns, verbs, adjectives, adverbs), longer words, sentence-initial words, and stressed syllables. - Preschoolers stutter more on: Pronouns and conjunctions (often at the beginning of utterances/syntactic units), suggesting a trigger related to linguistic planning.
Fluency-Inducing Conditions - Conditions that improve fluency: Speaking alone, being relaxed, speaking in unison, shadowing, speaking to animals/infants, singing, rhythmic stimuli, different dialects, simultaneous writing, swearing, slow/prolonged speech, loud masking noise, and delayed auditory feedback (DAF). - Likely due to decreased demands on speech-motor control and language formulation.

Stuttering: Characteristics of Disfluency (Lecture 2)

Lecture Objectives - Differentiate between Typical Disfluencies and Stutter-like Disfluencies (SLDs).
Typical Disfluencies (Nonstuttering-like) - Common in speech of individuals who do not stutter, especially between ages $2$ and $4$ . - Types: Multisyllable word repetitions ("Lassie Lassie is my friend"), Phrase repetitions ("I want a.. I want a cheeseburger"), Revisions/Incomplete phrases ("I don't.. where is daddy?"), and Interjections ("I went to the.. uh.. carnival"). - Units: $1$ or sometimes $2\,\text{units}$ per repetition. - Total Frequency: No more than $10\,\text{disfluencies}$ per $100\,\text{words/syllables}$ . - Secondary Behaviors: Typically none. - Feelings/Attitudes: Rarely notice disfluencies; no evidence of embarrassment or frustration.
Stutter-like Disfluencies (SLDs) - Proportion: If SLDs make up more than $50\%$ of total disfluencies, the child is likely stuttering. - Types: Part-word repetitions, Single-syllable word repetitions, Prolongations, Blocks. - Units: More than $2\,\text{units}$ per repetition (e.g., "li-li-li-like," "you you you can go"). - Nature: Faster repetitions with more physical tension. - Feelings/Attitudes: Awareness of difficulty, signs of frustration, and negative feelings.

Assessment of Stuttering

Levels of Assessment 1. Information Gathering: Interviewing, measuring fluency, administering tests. Requires planning and thorough analysis. 2. Personal Encounter: Connecting with the client and family; picking up subtle signals about needs and providing an opportunity for the client to know the clinician.
Privacy and Ethics - Establishing trust to reveal personal information. - Sensitivity to what is shared with family/peers. - HIPAA: Health Insurance Portability and Accountability Act of 1996 provides guidelines.
Assessment Components - Frequency, Type, Duration, and Severity. - Secondary Measures: Speech naturalness, speech rate, and concomitant behaviors. - Stuttering counts include: Part-word repetitions, monosyllabic whole-word repetitions, sound prolongations, blockages, and unequivocal avoidance behaviors.
Speech Sampling - Collect at least two samples. - Sample 1: Clinic setting. - Sample 2: Home (preschoolers), school (school-age), or work/phone (adults). - Length: Conversation samples should be $300\text{--}400\,\text{syllables}$ ; Reading samples should be $200\,\text{syllables}$ .
Calculating Frequency - Percentage Syllables Stuttered (%SS): - $\text{\%SS} = \frac{\text{Total Stutters}}{\text{Total Syllables}}$ - Each syllable is counted only once, even if multiple disfluencies occur on it (e.g., "ba-ba-ba-ba-basketball" = 1 stutter). - Obvious avoidance behaviors without an audible stutter are counted as stutters (e.g., "My name is uh… uh… uh… Barry" = 1 stutter).
Assessment Tools: Severity and Naturalness - SSI-4 (Stuttering Severity Instrument-4): Measures frequency (%SS), duration (average of three longest stutters), and secondary behaviors (0-20 scale for physical concomitants like facial grimaces). - TOCS (Test of Childhood Stuttering): For ages $4\text{--}12$ . Includes Speech Fluency Measure, Observation Rating Scale, and Supplemental Clinical Assessment. - SR Scale (Child Stuttering Severity Scale): A $0\text{--}10$ scale used by parents daily ( $0 = \text{none}$ , $10 = \text{extremely severe}$ ). - Naturalness Scale: Included in SSI-4 to ensure therapy doesn't produce weird or unnatural speech.
Speaking and Reading Rates - Measured in syllables per second or minute. - Adult Norms: $162\text{--}230\,\text{syllables/min}$ . - Ages 2-3 Norms: $169\text{--}213\,\text{syllables/min}$ .
Assessing Feelings and Attitudes - ISPP (Impact of Stuttering on Preschoolers and Parents): Questionnaires for children (talking difficulty), playmates (teasing), and parents (emotions). - A-19 Scale: For school-age communication attitudes. - Modified Erickson Scale of Communication Attitudes (S-24): - Stutterers Mean Score: $19.22$ ( $9\text{--}24$ range). - Nonstutterers Mean Score: $9.14$ ( $1\text{--}21$ range).
Fluency Count Formulas and Thresholds - Total Dysfluencies (TD): #\text{nSLD} + #\text{SLD}. - Markers: - $\ge 10\,\text{TD per 100 words}$ suggests a Child Who Stutters (CWS). - $\le 10\,\text{TD per 100 words}$ (approx $8\%$ ) suggests a Child Who Does Not Stutter (CWNS). - $\ge 3\%$ SLDs/100 words is a marker to assess further.

Treatment of Stuttering

Essential Clinician Attributes - Empathy: Deep and accepting listening. - Warmth: Caring and unconditional acceptance. - Genuineness: Honesty and self-acceptance; blunt when needed.
Primary Treatment Goals 1. Reduce negative feelings and attitudes. 2. Reduce abnormality of stuttering (modification). 3. Reduce frequency of stuttering. 4. Reduce avoidance. 5. Increase communication abilities. 6. Create a fluency-facilitating environment.
Cognitive-Behavioral Therapy (CBT) - Based on the notion that perception determines behavior. - Aims for a realistic and compassionate self-view. - Explores how thoughts affect feelings, which affect behaviors (e.g., changing negative self-talk).
Stuttering Modification Strategies - Modified moments of stuttering to be less severe. - Guitar (2025) Steps: - Understanding: Discuss logical core/escape behaviors to desensitize. - Exploring/Changing in Room: "Catch and hold" stutters to feel physical tension; learn to stutter "slowly and loosely." - Exploring/Changing Outside: Generalize control with different listeners.
Fluency Shaping Techniques - Flexible Rate: Slowing production when stuttering is expected. - Easy Onset: Gently starting vocal fold vibration. - Light Contact: Softly touching articulators to keep airflow going. - Operant Conditioning: Rewarding fluent speech; mild punishment (tactful "do-overs").
Reducing Avoidance and Increasing Skills - Voluntary Stuttering: Stuttering on purpose to reduce the fear of stuttering. - Avoidance Hierarchy: Developing a list of speaking situations from easy to difficult. - Communication Skills: Training in turn-taking, eye contact, and repairing breakdowns.
Facilitating the Environment (Family Interaction Patterns) - Listening Time: $5\text{--}10\,\text{minutes}$ of dedicated, distraction-free time daily. - Slow Rate: Using a soothing, calm style with comfortable pauses. - Pauses: Pausing $1\text{--}2\,\text{seconds}$ before starting to speak. - Fewer Questions: Limiting demanding questions that put the child "under the gun."

Swallowing and Dysphagia: Physiology

General Definition of Swallowing - A coordinated pressure system with airway protection layered on top. - Structures open, close, and squeeze to clear the mouth (tongue), clear the throat (tongue base/pharynx), protect the airway (larynx), and open the esophagus (PES).
Oral Stage Physiology - Openers/Closers (Containment): Lips and jaw open to accept and close to contain food. - Tongue-to-Palate Seal: Keeps food in the oral cavity until coordination triggers movement to the pharynx. - Squeeze (Clearance): Tongue squeezes against the hard palate. - Inefficiency: Manifests as oral residue (more than a functional "coating").
Pharyngeal Stage Physiology - Openers/Closers: Nasal cavity is closed; larynx is closed; esophagus is opened. - Squeezers: Tongue and pharynx (2:1 ratio of movement). - Timing: Onset should ideally happen near the anterior faucial arches or vallecula. - Laryngeal Closure Sequence: 1. Arytenoids medialize (Vocal cords close). 2. False folds close/medialize. 3. Arytenoids tilt in to meet the epiglottic base. 4. Epiglottis folds over the laryngeal inlet.
Swallow Safety Metrics - Penetration: Bolus enters the laryngeal vestibule (green area) but stays above the vocal cords (yellow area = to the cord). - Aspiration: Bolus passes below the vocal cords (red area).
The Esophageal Opener (PES) - PES (Pharyngoesophageal Sphincter): Also called the cricopharyngeal muscle. It is closed at rest. - Relaxation: The brainstem triggers PES relaxation as the pharyngeal swallow starts so it is open before the bolus arrives.

Swallowing and Dysphagia: Treatment

Treatment Categories - Dietary Modifications: IDDSI level changes. - Compensatory/Strategy-based: Immediate changes in flow/gravity. - Rehabilitative: Physiological improvement (strength/skill). - Medical: Surgical or pharmacological interventions.
Diet Levels (IDDSI Framework) - Liquids: Level 0 (Thin), Level 1 (Slightly thick), Level 2 (Mildly thick), Level 3 (Moderately thick), Level 4 (Extremely thick/Pureed). - Solids: Level 3 (Liquidized), Level 4 (Puree), Level 5 (Minced & Moist), Level 6 (Soft & Bite-sized), Level 7 (Easy to Chew/Regular).
Compensatory Strategies - Chin Tuck: Helps slow liquid flow and close the larynx; however, it can worsen aspiration in some patients if it narrows the airway inappropriately. - Head Rotation: Rotating to the left or right closes off the weak side of the pharynx and pulls open the PES. - Behavioral Changes: Smaller sips/bites, avoiding sequential drinking, slowing rate, and upright positioning.
Rehabilitative Exercises - Iowa Oral Performance Instrument (IOPI): Air-filled bulb for tongue/lip resistance training with visual biofeedback. - Effortful Swallow: "Swallow hard" or "squeeze with your throat." Improves hyolaryngeal elevation and pharyngeal constriction. - Mendelsohn Maneuver: Initiating a swallow and holding the larynx at its peak elevation for several seconds. Improves laryngeal closure and PES opening duration. - Surface Electromyography (sEMG): Biofeedback tool to measure the amplitude and timing of muscle contractions (e.g., Normal swallow ~ $0.5\,\text{seconds}$ ; Mendelsohn ~ $4\,\text{seconds}$ ). - Respiratory-Swallow Patterning: Training the patient to sequence: Take breath -> Hold breath -> Swallow -> Breathe out. Focuses on motor learning rather than strength.
Sample Plan of Care (POC) - Recommend IDDSI Level 6 (soft/bite-sized) solids. - Thin liquids (IDDSI 0) but with special strategies (breath hold prior to swallow). - Limit sip volume to $10\,\text{ml}$ . - Use effortful swallow for rehabilitation to improve pharyngeal strength.