Fluency Disorders

Fluency: continuity, smoothness, rate, and effort in speech production

Disfluency: disruption to the forward flow of speech

Typical Disfluencies: fillers, word or phrase repetition

Atypical Disfluencies: fluency disorder

Stuttering

• interruption to the forward flow of speaking characterized by:

  • part-word repetitions

  • prolongations

    • sound is held out in duration longer than what is typical

  • blocks (inaudible fixed posture)

    • block or stop in speech production that isn’t planned; stuck in one spot and cannot move on; happen on consonants more often, and typically occur at the beginning of words

• Can co-occur with other disorders like:

  • attention-deficit hyperactivity disorder (ADHD)

  • Autism Spectrum disorder (ASD)

  • Language or Learning Disability

  • Speech Sound Disorders

Cluttering

• breakdown in speech clarity and fluency that result from:

  • atypical pauses

  • syllable deletion

  • excessive interjections

    • other words that include high ends of emotion “wow, oh!, cool!”

• Can co-occur with other disorders like:

  • learning disability

  • Tourette’s Syndrome

  • Autism Spectrum Disorder (ASD)

  • Anomia

  • Attention-Deficit Hyperactivity Disorder (ADHD)

Incidence and Prevalence

• Stuttering

  • 2% of children ages 3-17 years old stutter

  • Ages 21-50, .78% of them stutter

  • 51 and up, .37% of them stutter

  • Not a very prevalent disorder

  • Among children and adults who stutter around 1/3 of them also experience some components of cluttering

• Cluttering

  • Even less common

  • About 1% of school-age children clutter

Developmental Stuttering

• symptoms of stuttering appear when the child is between the ages of 2 and 5

• Some stuttering in this age range is normal

• This stuttering happens when a child's Speech and language development lag behind their desire to communicate

• When symptoms last for 3-6 months between ages 2-5 without showing improvement, this indicates life-long stuttering may happen

• Cause and Risk factors- Don’t have exact cause, there are some factors that make you more or less likely to stutter, but there isn't a test to determine why someone stutters

  • Genetic factors

    • There are genetic factors, so if a father has or had a stutter, their child may have a stutter

  • neurophysiology factors

    • differences in white and grey matter, reduced blood flow, neural network connectivity differences

  • sex

    • biological males are at a higher risk to stutter than females

  • age of onset

    • Children that end up with developmental stuttering that persists, they begin to stutter at age 3.5 or later

  • time duration of symptoms

    • Individual will likely keep stuttering into adult when symptoms persist for 6-12 months with no improvement

• Signs and Symptoms

  • Primary, Core Speech Behaviors

    • Monosyllabic whole-word repetitions

      • repetition of single syllable word

      • ex: “why why why is she sad”

    • Part-word repetitions

      • part of a word, sound or syllable, is repeated

      • ex: “L L L Look over here”

    • prolongation

      • extended duration of sound or syllables beyond what is considered typical

      • ex: “shhhhow me how”

    • Blocking

      • inaudible fixed posture, or inaudible silent fixation

      • silence is not expected, but it is inputted into speech

      • ex: “_silence___Nod my head yes”

      • often a block is associated secondary behaviors

    • Production of word with excess physical tension

      • higher pitch to their voice, pressed voice quality, louder speech, extra tension in their tongue

  • Secondary, Concomitant Behaviors-

  • learned response that individuals who stutter adopt and happen at the same time of stuttering and can make the perception of their stuttering worse (occur in conjunction with primary behaviors)

    • body movements

      • ex: nodding your head, tapping your leg, shaking your head

    • facial grimaces

      • ex: eye blinking, tightening of the jaw

    • distracting sounds

      • ex: throat clearing, coughing, tongue clicking, lip smacking

  • Avoidance, Escape Behaviors

  • speaker uses different techniques to temporary conceal stuttering behavior and avoid stuttering moment

    • use of fillers

      • ex: “um, uh, like, ya know”

    • avoidance of sounds or words

      • ex: avoid sounds or words that they know they will have an issue with

    • altering rate of speech

      • slow down their speech or make it faster

      • speech rate with become irregular

        • ex: talking normally then speed up their rate, or slow it down

• Overt Stuttering

  • someone with overt stuttering displays Primary, Core Speech Behaviors and Secondary, Concomitant Behaviors

• Covert Stuttering

  • Avoidance, Escape Behaviors are present so much so that primary and secondary behaviors are not obviously present

  • talks with a lot of fillers and they alternate their rate of speech

The Experience of Stuttering: Emotional Impact

• your client who stutters may have any combination of the following emotions and impact from their experience as a person who stutters:

  • a sense of loss of control

  • increased social anxiety

  • shame and guilt

  • negative thoughts and feelings about oneself

  • rumination on perceived communication failures

  • decreased sense of self-worth

  • depression (involve emergency services or refer to a psychologist)

  • suicidal ideation (involve emergency services or refer to a psychologist)

  • avoidance of words/sounds, speaking, and/or social interactions

  • perceived judgment of communication by others

  • perceived negative effects on social and/or romantic relationships

  • perceived career barriers related to communication

• Cluttering (less common of the two fluency disorders)

  • causes and risk factors- exact cause is unknown

    • neurological factors

      • high prevalence of cluttering along with other disorders like ASD, Tourette’s, or ADHD

    • self-regulation factors

      • thoughts emerge before they’re ready

      • “speaker’s mind is working faster than the body”

    • sex

      • males are at a higher risk than females; 3 to 6 times as likely for a male to clutter than a female

    • family history

      • child is more likely to develop cluttering if a family member has cluttered

    • presence of other co-occurring disorders

      • can cooccur ASD, ADHD, or Tourette’s

    • presence of stuttering

      • presence of stuttering makes it more likely for you to clutter

  • Signs and symptoms

    • excessive coarticulation

      • where we collapse or ‘delete’ syllables and word endings

      • “I was liking the park” but for someone who clutters might say “I was like the park”

    • excessive typical disfluencies

      • non-stuttering disfluencies, but included things like excessive revisions and use of filler words

      • ex: “No um um um um no like that”

    • abnormal pauses

      • pauses in places that don’t make sense syntactically and within the message

      • ex: “I like pancakes in the morning” —> “I like pancakes in [pause] the morning“

    • rapid/irregular speech rate

      • too fast and impacts intelligibility

      • trying to get all their words out before the stutter

    • unusual prosody

      • with fast rate and abnormal pause it is unusual to listen to

Assessment Procedure in Fluency Disorder

• Case history

  • pertinent medical history

    • important in acquired stuttering

  • parent, guardian, patient report

    • important to ask guardian or parent about the stuttering because they might have certain perceptions of the client’s stuttering that the client themself wouldn’t know

• Assessment

  • screenings

    • do this before a formal test because with stuttering there are disfluencies that are considered normal

    • can be a language sample

  • formal and informal testing

  • oral mechanism examination

    • mostly done to rule out anything else

  • stimulability

    • gives us an idea where to begin with treatment in the next step

• Analysis and Diagnosis

  • Disfluency Index

    • Primary, Core Speech Behaviors

  • Associated Behaviors

    • Secondary, Concomitant Behaviors

  • Rate of Speech

  • Feelings, attitudes, and reactions to speech

    • Avoidance, Escape Behaviors

Formal Tests in Fluency Disorders

• Stuttering Severity Instrument (SSI-4) - allows us to calculate and quantify their primary and secondary behaviors

  • Primary and Secondary Behaviors

  • Calculate Percent of Syllables Stuttered in Speech Samples

  • looks at reading and extended speech samples

• Overall Assessment of the Speaker’s Experience of Stuttering (OASES) - (survey based)

  • 3 different forms; Child, teenage, and adult version

  • asks all different questions about the individuals stuttering

• Approaches to Treatment in Stuttering

  • Main Goals of Treatment

    • reduce primary and secondary behaviors of stuttering

    • reduce negative reactions to stuttering

      • if you can reduce some negative reactions it can help reduce some primary or secondary behaviors, and vice versa

• Fluency Shaping Techniques

  • make changes to the timing and tension of speech production and pausing to improve fluency

    • easy onset

      • gradual onset of voicing at the initial of words and utterances

      • helps person slowly articulate initial onset of word to help ease disfluency

    • light articulatory contact

      • use easy articulatory postures, specifically think about stop consonants (using a /d/ for /t/)

    • continuous phonation

      • maintaining voicing throughout an utterance

      • basically not having pauses, we are trying to keep our voices on because stuttering will occur in pauses

    • prolonged syllables

      • stretching of each syllable in words or utterances

      • focus on slowing rate of speech and prolonging each individual syllable

    • rate control

      • slowing the overall rate of speech

    • pausing

      • adding syntactically appropriate pauses

      • can be bad for some people

  • can be utilized for children, teenagers, and adults

    • an example is Turtle-Talk

• Stuttering Modification Techniques

  • learn about the speech mechanism and how it operates during fluent and disfluent speech so the speaker can recognize and reduce disfluencies

    • preparatory set

      • speaker anticipates a moment of stuttering before it occurs and more effectively manages the moment of stuttering

    • pull-out

    • cancellation

  • Can be utilized for children, teenagers, and adults