10 Fluency Disorders

Chapter 10: Fluency Disorders

Focus Questions

  • What is a fluency disorder?

  • How are fluency disorders classified?

  • What are the defining characteristics of fluency disorders?

  • How are fluency disorders identified?

  • How are fluency disorders treated in evidence-based practice?

Introduction

  • Better known as stuttering.

  • Characterized by:

    • Stops, starts, and hesitations in speech.

  • Affects a relatively small number of people compared to other disorders of communication.

  • Prevalence:

    • Approximately 1 to 2% of the population are affected at any given time.


What is a Fluency Disorder?

  • Definition: A descriptive term used to characterize the flow of speech during communication.

  • Disfluency: Speech behaviors that disrupt the fluent forward flow, including pauses, interjections, and revisions.

  • Core and Secondary Features: Important terminology in understanding fluency disorders.

  • Prevalence and Incidence: Important metrics to be aware of in research and clinical settings.

Defining a Fluency Disorder

  • Definition: Speech characterized by an unusually high rate of stoppages that disrupt the flow of communication and are inappropriate for the speaker's age, culture, and linguistic background, including dialect.

  • Characteristics:

    • Disturbances in normal fluency and timing patterns.

    • Impact on social communication, academic performance, or occupational achievement due to fluency disturbances.

Core and Secondary Features

  • Core Features (Primary Characteristics):

    • Repetition

    • Prolongation

    • Block

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

  • Secondary Features: Behaviors that develop in response to primary characteristics.

Terminology

  • Stuttering: The disorder itself.

  • Stutterer: An individual who stutters.

  • Stuttering child: A child who exhibits stuttering.

Prevalence and Incidence

  • Fluency disorders affect relatively few individuals:

    • Prevalence rate: Approximately 1 in 100 persons. 1%

    • Incidence rate: Approximately 5 in 100 persons. 5%

    • Lifetime prevalence: Around 5% have stuttered at some point, but currently only 1% are actively stuttering.

    • Stuttering in children: 1.5% under age 10, compared to 0.5-0.7% in adolescents and adults.

Recovery from Stuttering

  • Recovery during treatment: termed assisted recovery.

  • Unassisted recovery: Spontaneous recovery without treatment, through self-management.

  • Discussion on whether treatment should be given to young stutterers due to high recovery rates.

Classification of Fluency Disorders

  1. Developmental Fluency Disorders (Ages 2-5):

    • Developmental stuttering

    • Stuttering-like disfluencies (e.g. part-word repetitions, single-syllable-word repetitions, sound prolongations, blocks, broken words).

  2. Acquired Fluency Disorders: Variety emerging from specific incidents in an individual’s life.

  3. Cluttering: Disorganized speech characterized by a rapid or unusual rate, resulting in disfluencies and unusual pauses.

Characteristics by Age Group

Preschoolers

  • Core behaviors include:

    • Repetitions of words/sounds

    • Sound prolongations

    • Blocking

  • Secondary behaviors: Head nods, eye blinks, interjections.

School-Age Children

  • Core behaviors include:

    • Prolongations and blocks becoming more prevalent.

  • Secondary behaviors:

    • More evident and habitual, leading to feelings of helplessness and embarrassment.

Adolescents and Adults

  • Core behaviors are similar to school-age children, but less evident.

  • Advanced stuttering includes sophisticated avoidance and escape strategies.

Acquired Fluency Disorders

  • Can appear at any age due to:

    • Illness, trauma, or psychological issues.

    • Two types: Neurogenic stuttering and psychogenic stuttering.

Defining Characteristics of Fluency Disorders

  • The most conspicuous feature is disruptions in speech characterized by:

    • Primary: sound and word repetitions, sound prolongations, blocks.

    • Core Features and Secondary Features: Lead to the overall impact on individual communication.

Core Features of Fluency Disorders

  • Definition: Emphasizes speech disfluencies as the primary source of communicative difficulty.

  • Types of disruptions:

    • Part-word repetition: Up to 5/100 syllables.

    • Single-syllable-word repetition: 3+/100 syllables.

    • Sound prolongation.

    • Blocks (commonly observed in intermediate and advanced stuttering).

Secondary Features

  • Escape Behaviors: Used to terminate disfluency, such as physical gestures.

  • Avoidance Behaviors: Include:

    • Word and sound avoidance.

    • Circumlocution is chaning words to avoid stuttering

    • situation avoidance.

  • Feelings and attitudes towards stuttering can exacerbate the disorder.

Causes and Risk Factors

  • The underlying cause of stuttering remains unclear. Factors contributing to fluency disorders include:

    1. Predisposing Factors (or constitutional factors):

    • Family history.

    • Gender predispositions.

    • Neural morphology differences.

    • Motor-speech coordination difficulties.

    1. Precipitating Factors: Events or stressors triggering stuttering episodes.

Can Stuttering Be Induced?

  • Discussion on the Diagnosogenic theory of stuttering illustrated by the "Monster Study"—exploring if diagnosis contributes to the stuttering itself.

Identification of Fluency Disorders

  • Identification can be complicated as nearly all individuals exhibit some disfluency.

  • Metrics for Identification:

    • Average number of disfluencies per 100 words.

    • Average number of disfluencies per 100 syllables.

Assessment Process

  1. Referral: Speech-language pathologists are the professionals trained in assessing and diagnosing fluency disorders.

    • Warning signs for developmental and acquired fluency disorders are outlined for recognition.

  2. Assessment Protocol: Involves four questions:

    • Is the individual stuttering or at risk of stuttering?

    • Are there other communicative risk factors or disabilities?

    • Is therapy warranted?

    • What therapeutic approach is most beneficial?

  3. Assessment Techniques:

    • Case history and interview.

    • Speech observation.

    • Questionnaire and survey.

    • Direct testing.

Diagnosis

  • A fluency disorder is likely diagnosed under the following observations:

    • Ten or more total disfluencies in 100 words.

    • Three or more stuttering-like disfluencies in 100 words.

    • Presence of physical escape behaviors.

    • Presence of verbal avoidance behaviors.

    • Use of the Stuttering Severity Index (SSI, Riley, 1972) for assessment.

Prognosis

  • Prognosis describes the likelihood of resolution of symptoms:

    • Factors that impact prognosis include:

    • Age at onset of stuttering.

    • Duration since onset.

    • Nature and quantity of core and secondary features.

    • Presence of individual risk factors.

Treatment of Fluency Disorders in Evidence-Based Practice

  • Treatment approaches vary across developmental stages:

    • Techniques for children, adolescents, and adults are distinct.

  • Emphasize:

    • Knowledge about stuttering.

    • Reduction of negative emotions.

    • Fluency building for effective communication.

    • Perspectives of clients and caregivers in therapy.

Treatment Techniques for Children

  • Consideration of whether children with borderline stuttering should pursue treatment or observe a wait-and-see approach.

Parent-Implemented Treatment

  • Also known as indirect treatment.

  • Environmental models:

    • Avoid placing child on the spot.

    • Behaviors include repeating child’s speech to emphasize active listening.

    • Comments more than questions during conversations.

    • Modify stressful activities.

  • Operant training models:

    • Lidcombe program: focuses on identifying disfluencies, providing positive feedback, prompting fluency and self-correction.

Clinician-Implemented Treatments

  • Current approaches include:

    • Stuttering Modification.

    • Controlled Stuttering.

    • Fluency Shaping.

    • Controlled Fluency techniques.

Treatment for Adolescents

  • Special considerations for treating adolescents with intermediate or advanced stuttering.

  • Both modification and shaping strategies are applicable:

    • Education about stuttering to demystify the condition.

    • Successful Stuttering Management Program phases:

    • Phase 1: Confrontation of stuttering.

    • Phase 2: Modification of stuttering.

    • Phase 3: Long-term maintenance.

Treatment Techniques for Adults

  • Treatment modalities for adults include elements from both stuttering modification and fluency shaping approaches, or a combination of the two:

  • Focus on:

    • Understanding stuttering.

    • Reducing negative emotions associated with it.

    • Building fluency.

Client and Caregiver Perspectives Related to Treatment

  • Recognition that fluency disorders impact speech, self-esteem, and emotional well-being significantly.

  • Collaboration between parents and children is vital for effective treatment.

  • Adolescents and adults must address the implications of stuttering on their lives.