FLUENCY DISORDERS EXAM 1

IDENTIFYING FLUENCY DISORDERS

developmental stuttering, also defined as “childhood-onset fluencey disorder” in the DSM-5, is a type of fluency disorder
we often identify stuttering in terms of it’s typical types of disfluencies such as sound or syllable repitions, audible sound prolongations, or silent prolongations
stuttering’s actual occurrence may take other forms: * word substitutions * anxiety about speaking or limitations in effective communication * social participation * academic/ occupational performance
the hallmark includes an abnormal (unnatural) disruption of speech fluency/ disruption in the normal flow of speech
stuttering is best described as a syndrome, in that it encompasses a wide variety of behaviors & no single individual may exhibit all the behaviors * each individual has a unique constellation of behaviors that constitute their pattern of stuttering
stuttering is also typically identified as having an onset in early childhood, with greatest prevalence occurring by age of six * many authors use the term “developmental stuttering” or “childhood stuttering” to identify that form from the much rarer type that has it’s onset in adolescence or adulthood
all speakers experience various forms of disfluency during speech production/ some types are considered typical for normal speakers
overt behaviors:
easily observed
may include the actual disfluency (ex. repetition, prolongation)
may include a variety of accompanying behaviors (ex. facial grimaces, word interjections)
covert behaviors: * unseen or difficult to observe * ex. fear of the situation, or fear of stuttering on the upcoming word

NORMAL NONFLUENCIES

all speakers experience disfluency during speech production
the following are the type of disfluencies that predominate the speech of normal (nonstuttering/ people who don’t stutter (PWDS)) speakers: * silent pauses * interjections of sounds, syllables, words * phrase or sentence revisions * phrase or whole-word repetitions * sound or syllable repetitions (easy/ effortless, usually only about 1, 2, or 3 units repeated)

CORE STUTTERING BEHAVIORS

stuttering is generally thought to go through developmental pahses
the following are the predominate behaviors that generally signal the onset of stuttering in children or people who stutter (CWS/PWS): * any of the “normal nonfluencies” done excessively * sound or syllable (also referred to as “part-word”) repetitions, especially with multiple repetitions (unit/ sounds or syllables repeated more than 2-3 times) * sound prolongations (also referred to as “audible prolongation”) * centralized vowel productions (also referred to as “schwa insertion”) within the repetitions * fixed articulatory postures (also referred to as “blocks” or “silent prolongations”) * visible tension of speech musculature * difficulty starting or sustaining voicing and/ or airflow

STUTTERING-LIKE DISFLUENCY VS OTHER DISFLUENCIES

stuttering-like disfluency: * part-word repetition * single-syllable word repetition * dysrhythmic phonation
other disfluencies (more typical to normally fluent speakers) * phrase repetition * revision * interjection

ASSOCIATED (SECONDARY) SYMPTOMS

disfluencies are not the only feature that define stuttering
Van Riper (1971) provided one definition of stuttering: a moment of stuttering consists of a word improperly patterned in time (the disfluency) & the speaker’s reaction thereto * as stuttering develops, the individual begins to anticipate difficulty & fear situations, particular words, and all words beginning with specific phonemes * in response, the individual begins to adopt a variety of behaviors to avoid stuttering and/ or physically break out of a moment of stuttering when “trapped” in it
joseph sheehan (1958) uses the iceberg analogy with the actual disfluencies being the tip of the iceberg & the associated/ secondary symptoms hidden beneath the surface with the greatest mass
categories of associated symptoms: as stuttering develops, the individual begins to anticipate difficulty & fear situations
Charles Van Riber (1963) provides a theoretical classification schema for these: * avoidance behaviors: attempts to evade moments of stuttering (ex. word substitution, circumlocution) * postponement behaviors: attempts to delay production of feared word/ sound (ex. pauses, repetitons of preceding word, interjections, acting as if trying to recall) * it is theorized this is an attempt to allow the initial panic/ dear of an anticipated stuttering event to subside * starting/ initiating behaviors: attempts to alter initiation of sound production to make it easier (ex. associated movements such as grimace, rapid inhalation/ exhalation, head jerk, arm slapping on leg, or “starter” sounds such as “uh” prefixed to the word") * escape behaviors: attempts to terminate the stuttering event once engaged in it (ex. head jerk, gasp, speaking on residual air, back IP to previous portion of utterance & repeat) * antiexpectancy behaviors: attempts to alter, mask, or distract oneself to keep from triggering a stuttering event (ex. speak in monotone, or speak very rapidly, or speak with accent)
examples of associated symptoms: * visible/ audible (OVERT) reactions: * accompanying physical movements: eye blinking, wrinkling of forehead, sudden exhalations, frowning, head jerk, lip smacking, arm/limb movements, etc. * interjected speech fragments: often stereotypical, superfluous, or used inappropriately (ex. “um”, “er”, “you know”, “well, you see”, “in other words”) * abnormal patterns of speech or voice: rapid rate, slow rate, inappropriate pitch, monotone or monoloudness, excessively loud or soft speech, stilted or accented intonational pattern * skin/ autonomic reactions: flushing, pallor, excessive perspiration during speech attempts, etc. * physiological: “difficult to see/ hear” (COVERT) reactions: * unusual eye movements: nustagmotic oscillations, eyes fixed, temporary strabismus, vertical twitch * cardiovascular changes: accelerated heart/ pulse rates, increased blood pressure accompanying speech * tremor: lip tremor during block, increased normal hand tremor rate * dyssynchronous brain activity: change in predominate frequency rate, regularity, or interhemispheric patterns * biochemical composition: increased adrenaline, noradrenaline, & dopamine levels * electrodermal responses: increased palmar sweating & galvanic skin response levels * psychological/ introspective (COVERT) reactions: * muscular tension: generally localized to specific portions of the speech musculature (ex. jaw, larynx, tongue) or other body areas * affective reactions: apprehension of impending difficulty, general unease or even panic; ability to anticipate difficulty; confusion or “loss of contact” during blocks; feeling of frustration, exasperation, and/ or embarrassment after blocking * frustration in speech attempts: feeling of complete inability to successfully produce word/ utterance

LOCI OF STUTTERING (BROWN, 1937)

typical location of stuttering events in speech production * positional factors: * more likely on first phoneme of word * more likely on first word of utterance * more likely in earliest occurring words of utterance * phonetic factors: * no universal pattern/ very individualized * more likely on initial consonant than initial vowel * no cleat link to motor complexity of phoneme * may be experientially based * grammatical factors: * after established/ chronic, occurs more frequently on content words (nouns, verbs, adjectives, adverbs) * less likely on “function” words (articles, prepositions, pronouns, conjunctions) * word length factors * greater the length, more likely it is to be stuttered (ex. monosyllabic words are least likely to be stuttered; trisyllabic, quadrasyllabic, etc. words are much more likely to be stuttered) * word frequency (frequency of occurrence) factors: * less frequently a word is commonly used in a language, the greater the probability that stuttering will occur on that word (common words vs. scientific/ technical words) * predictability factors: * greater the information load a word carries (ex. less likely it is for listener to be able to predict what the word will be), the greater the likelihood that stuttering will occur on that word)

COMMUNICATION PRESSURE

various types/ aspects of communicative pressure have an effect on the likelihood of stuttering occurring: * communicative responsibility: the greater the propositionality (meaningfulness) of an utterance, the greater the probability of stuttering occuring * least likely on unconnected speech (word lists) or “automatic” speech (repeating days of the week, pledge the flag, greetings) * more likely as predictability decreases (introducing self, speaking out of context, using technical language) * more likely if asked to repeat previous utterance * time pressure: more hurried the nature of a conversation, the more likely to stutter * responding to questions, introducing self, talking on telephone (require response is short length of time) * talking to fast speakers (tendency is to respond at rate speaker is using) * communication competition (if someone else is competing for the conversational floor) * motoric difficulty of utterance: more complex the utterance (greater length, faster rate, use of less frequently occurring words, technical complexity) more likely for stuttering to occur * social factors/ concern for social approval * previous negative listener reaction makes stuttering more likely to occur with that person/ that situation in the future * perceptions of listener personality (less likely with easygoing, nonjudgmental type than with critical, impatient listener) * degree of authority (more likely to stutter with people perceived to be in superior position (teacher, supervisor, police officer) & less with those in inferior position (children, pet) * familiarity (more likely with strangers than with family, close friends) * audience size: as size of audience, number of listeners increases, so does probability of stuttering * attentional factors: the more the individual is paying conscious attention to the act of speaking itself, the greater the probability of stuttering * sometimes referred to as “de-automatizing speech”, not letting it be produced automatically/ reflexively

EFFECT OF NOVEL MODES OF SPEAKING

if a PWS changes the way he/she speaks, it is often likely to reduce the probability of stuttering occurring (at least initially), (think about Van Riper’s “antiexpectancy behaviors”) * some examples may include: * monotone * whisper * singing * sing-song pattern * shouting * pitch shifts * unusual voice quality * exaggerated articulatory movements * slow rate * altered breathing * paced (metronome) * foreign dialect * impersonating others * acting/ dramatic style * altered personality * choral speaking or shadowing

MISCELLANEOUS FACTORS

emotional arousal: stuttering is often reduced during moments of excitement, motivation, or strong emotion (may be distraction/ attention factor)
intense or unusual stimuli: stuttering is often reduced when exposed to unusual stimuli or situations, such as: * auditory masking (high amplitude) * narcotics/ psychotropic medication * anesthesia (may be site dependent) * extreme pain * extreme fatigue

\ PREVALENCE & INCIDENCE

prevelance: degree to which a disorder exists at any particular time (ex. how many people currently stutter) * generally given as 1% of school-aged children & less than 1% in adulthood (approx. mean across cultures)
incidence: index of how many people have stuttered at some point in their lives * results & outcomes depend on how stuttering defined by participants * research results range up to 15% of population has stuttered at some point * to better define it as stuttering researchers often ask in terms of duration * 5% of population has stuttered for at least 6 months (considered more accurate)
age at onset: may begin any time, at initial onset of connected speech (18 mo) through adulthood * approx 50% of cases show onset before the child is 4 years old * next 25% show onset by 6 yrs of age (75% of cases) * next 20% have onset by 12 yrs of age (95% of cases) * less than 5% of population show onset in adolescence or adulthood
sex ratio for incidence (males vs females) * the prevalence is often given as a 3 to 1 ratio of males to females (3:1) for US schoolchildren * ratio appears to increase to 4 or 5 males to each female (4:1 or 5:1) as move into adulthood * the increase in discrepancy btw males & females is thought to most likely result from a greater percentage of females recovering than males
familial incidence: there is an indication of a fairly strong genetic link in stuttering although percentages vary widely among studies (possibly due to differences in definition) * 33%-66% of CWS/PWS will have at least 1 first degree relative who stutters * only 5%-18% of CWDS/PWDS will have at least 1 first degree relative who stutters * much higher incidence of both twins stuttering in identical (monozygotic) twins - 80% of identical twins will both stutter/ if one non-identical twins (dizygotic/ fraternal) stutters there is only a 10% chance the other twin will stutter * no clear genetic predictive pattern has yet been discovered * some authorities account for the familial patterns as a result of the child being exposed to other family members who stutter, thus “learning to stutter”; however, many cases have been documented in which familial stuttering is observed w no contact to PWS in family * in last 10 years, NIH (national institutes of health) has published new information/ chromosomal differences have been observed, and genes linked to stuttering have been identified

EXAMPLES OF GENETIC PATTERNS

recovery patterns: a large number of children recover from stuttering (often independent of therapy)/ the actual number is unknown, but estimates range from 23%-80% of children * bloodstein (1987) reviewed a large number of studies & reported recovery figures ranging from 36%-76% of PWS * andrews & harris (1964) followed a group from onset to teen-age years & reported 79% recovered (they used a very liberal definition of “stuttering”) * Andrews (1983) reviewed the research & reported figures of 23% to 80% * the reasons percentages vary so much depends on a number of different factors, such as how stuttering was defined (ex. were some of the cases just normal confluency rather than stuttering?) & whether self-reporting or actual observation by professionals was utilized * if one considers the difference between prevalence (1% of population) & incidence (5% stuttered at same point in their life) figures, that would imply that 4/5 who stuttered for a period in childhood recover from their stuttering (4/5=80%)

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