SPH 620 Fluency Disorders

Lecture 1: 8-30-22 + 9-6-22

  • Peter Raming
  • Phil Schnieder
  • Stutter Talk
  • Stuttering Foundation Assignment (look back on syllabus)
  • C. If you Stutter: Advice for Adults https://youtu.be/QBrRnNtTiT0
  • Child seems to be acutely aware and anxious about his stuttering Grandparents ask child many questions when they come to visit
  • The Body and Soul of Therapy
  • Jenny and Austin

 

Terminology

  • Person first terminology
  • Persons who stutter
  • Dysfluent
  • Dys = dysfunction/atypical
  • Disfluent
  • Dis = typical people that exhibit
  • like kids, second language learners, dysarthrias, anxious people
  • Fillers - “um, like, ugh” + pauses in speech/stalling
  • Whole words: “what - what - what”
  • Stutter-free speech
  • A person who stutters that have a period of no stuttering
  • Fluency/fluent
  • Proficiency, knowledge, use of a language
  • Stuttering moment, moments of stuttering
  • Stuck wods, bumpy words

What is a fluency disorder?

  • WHO
  • Disorders in the rhythm of speech, in which the individual knows precisely what he wishes to say, but at the time is unable to say it because of an involuntary, repetitive prolongation or cessation of a sound.
  • Wingate’s definition (MOST CITED)
  • \

      1. (a) Disruption in the fluency of verbal expression, which is (b) characterized by involuntary, audible or silent, repetitions or prolongations in the utterance of short speech elements, namely: sounds, syllables, and words of one syllable. These disruptions (c) usually occur frequently or are marked in character and (d) are not readily controllable.
  • \

      2. Sometimes the disruptions are (e) accompanied by accessory activities involving the speech apparatus, related or unrelated body structures, or stereotyped speech utterances. These activities give the appearance of being speech-related struggle.
  • \

      3. Also, there are not infrequently (f) indications or report of the presence of an emotional state, ranging from a general condition of "excitement" or "tension" to more specific emotions of a negative nature such as fear, embarrassment, irritation, or the like.

Describing Stuttering (slide 7)

  • Some problematic wording because children, 2LL can do this

Core behaviors

  • More than 2x repeating
  • “I li-li-li-li-li-like this” = 1 stutter when counting
  • Syllable rep → “history” his-his-his-history
  • Phrase level rep → went to-went to-went to
  • Sound level rep → “b”
  • Prolongations - sound or airflow continues but movement of articulators is stopped
  • Prolongations as short as one-half second may be perceived as abnormal.
  • Ex: I liiiiiiiiiiiiiiiike tacos.
  • Blocks: inappropriate stoppage of airflow or voicing; movement of articulators may be stopped
  • Blocks may occur at any level—respiratory,                                                            laryngeal, and/or articulatory (cessation of sound)
  • Blocks may be accompanied by tremors of lips,                                                                tongue, jaw, and/or laryngeal muscles.
  • Superfluous Behaviors aka Interjections
  • Verbal →“Oh.. well… you..know..um”
  • Nonverbal →body movements! compressed lips, open mouth, breath holding, blinking, nostril dilating, eyebrow raising, increased rate of speech, fluctuations in pitch and loudness
  • Can happen when really excited or frustrated
  • Decrease when less tension occurs
  • Clustered Components - 2 or more core behaviors occurring
  • \
  1. Can have more than one time of stutter in one utterance!!!
  2. Not random - know when they are occurring
  3. Occurs w/
  4. Content words
  5. Stressed syllables
  6. Utterance length (shorter = better; longer = “nightmare”)

Affects of Stuttering in Someone’s Life

  • Speech
  • Education
  • Occupational
  • Psychological
  • Social
  • QOL - symptoms of (social) anxiety + anticipation

“experience anxiety or uncertainty when they anticipate stuttering”

“an attempt to hide or __escape __from an impending moment of stuttering”

  • DURING THE MOMENT

Avoidance = covert stuttering (before)

  • Circumlocutions
  • Substitutions, word avoidance
  • Someone who wants to pass as fluent
  • Perceive a reaction as real or no real (actually happening vs not happening - in the head)
  • Presents as typical to the outside world but is actually crippling for the individual
  • Someone w/ a stutter anticipates negative emotions before, during, and after an event

Stuttering

  • Psycholinguistic
  • Physiological
  • Psychosocial

ABCs of Stuttering

  • Affective
  • Behavioral
  • Cognitive

Basic Info:

  • Early stuttering - chance of natural recovery w/ or w/o treatment
  • 6-11 -NR is unlikely to occur
  • Persistent stuttering - no chance of natural recovery
  • May worsen over time
  • May decrease in prevalence and severity over time
  • Screening

Onset

  • May start as gradual increase in normal childhood disfluencies or may start as sudden appearance of prolongations or blocks
  • Often sporadic at outset, coming and going for periods of days or weeks before becoming persistent
  • Onset most often occurs between 2 and 3.5 years (average 2.8 years)
  • Boys may get diagnosed much later than girls because they typically develop language a bit delayed

Prevalence

  • A measure of how many people stutter at any one time

Incidence

  • The number of new cases during a certain period

Recovery

  • ⅔ or ¾ of stutters recover w/o treatment
  • Treatment focuses on affective and cognitive components of stuttering

Children with these attributes have less likelihood of spontaneous recovery (Yairi & Ambrose, 2005):

  • Having relatives who are/were persistent stutterers (70%)
  • Being male
  • Onset after 3.5 years
  • Stuttering not decreasing during first year after onset
  • Stuttering persisting beyond 1 year after onset
  • Multiple unit repetitions (li-li-li-li-like this)
  • Continued presence of prolongations and blocks
  • Comorbidity below than normal phonological skills; ADHD; speech and language disorder – CAUTION!!!!!

Brain Structure in Stuttering

  • Brain function and structure influence each other so that these categories are not actually separate influences on neural activity for speech
  • Overactivity in right hemisphere in areas homologous to speech areas in left hemisphere
  • Absence of activity or reduced activity in auditory areas used to monitor one’s own speech output
  • High levels of abnormal activity in cerebellum (coordination/movement)
  • Supplementary motor area (SMA) more active than in controls, especially during stuttered speech. Related to overactivation in basal ganglia
  • Less dense fibers in white matter tracts of left operculum. These fibers are thought to connect sensory planning and motor areas for speech

 

 

 

Differential Diagnosis

  • Acquired stuttering
  • Neurogenic
  • Drug-induced
  • Psychogenic
  • Cluttering
  • Tic syndromes (tourettes)
  • Neurological disorder
  • Speech-language disorders
  • Phonological
  • SLI

Lecture 2: 9-13-22

  • Theories drive practice
  • Gives us the “why”
  • Theories - more evidence to support them
  • Hypotheses - tentative propositions about theories
  • Models - explain how things work, use boxes, circles, lines, etc.
  • Why explain a cause for fluency disorders???
  • Explaining provides a way to cope with a disorder
  • Fundamental in our clinical practice
  • Causal Theories
  • Involves conditions that are necessary and sufficient for it to occur
  • Brain structure and function
  • Genetics
  • Onset during language development
  • Diagnosogenic Theory
  • Parents labeling stuttering in negative view made stuttering worse for children
  • Parents ear → child’s mouth
  • Monster Study
  • Multifactorial Model of Causality
  • Stuttering caused by an interaction of my many factors found in the environment and w/in the child
  • Intrinsic + extrinsic factors
  • Linguistic environment - is the parent calm? Languages? Advanced lexicon? Demanding?
  • Stress?
  • Family, friends, peers, teachers, etc.
  • No causal factors - nothing necessary/sufficient
  • You can’t test an environment or parenting style or take data
  • Unique to the child + circumstances
  • Demands and Capacities
  • Stuttering results from fluency demands related to the child’s social environment that exceed the child’s capacities
  • Dimensions that affect fluent speech production:
  • Cognitive
  • Linguistic
  • Motoric
  • Emotional

Van Riper

  • Van Riper (1982): disruption of timing of muscle sequencing = stuttering
  • Kent (1994): temporal programming disorder theory: deficit in central timing that regulates speech production and integrates left brain segmental and right brain suprasegmental aspects of speech production; this deficit produces stuttering.

Interhemispheric Interface Model

  • Supplementary motor area and interhemispheric activation
  • Origins from the Orton-Travis theory of cerebral dominance
  • Supported by brain imaging

•CWS have lower “phonological memory” than controls

•Poor performance with:

  • Verbal short-term memory
  • Sound blending
  • Elision tasks
  • Non-word rep. and non-word identification tasks

Packman-Attanasio 3-Model

Stuttering:

→neural processing deficit → activation of certain words/sounds is delayed/deactivated

→triggers → aspects of spoken language

→modulating factors → 1) internal and external stimuli 2) cognitive resources available

  • Supports anomalies in brain structure and function as responsible for stuttering, with a link to genetics
  • Provides a mechanism to explain onset during language development
  • Accounts for the influence of spoken language relating to stuttering
  • Accounts for affective and cognitive components
  • Does not account for recovery, sudden onset and why verbal contingencies can control stuttering and promote fluency

Lecture 3: 9-19-22

Stuttering Assessments

 1. Core stuttering behaviors?
 2. Initial sound repetitions ~ 2 sec
 3. Swtichng
 4. Prolongations?
 5. Blocks?
 6. On Initial sound + tension
 7. Cluster! - rep and blocks (more than 1 behavior on 1 word)
 8. Aware of stuttering?
 9. Oh- and ok now

  1. Switching - she wanted to say something but she selected another word to use
  2. \

Core behaviours? -

Reception at the initial syllable level

Prolongation

Blocks

Secondary? - multiple eye blinks, mouth twitched, leans forward, tension in the brows

Escape or avoidance behaviors? -

Feelings or attitudes? -

Lecture 4: 9-27-22

Assessment

  • Where do we start?
  • Formal way of documentation
  • Presents clear information
  • Sets our goals
  • Determines progress throughout treatment
  • Manages maintenance post-treatment
  • Quantitative
  • Frequency count
  • Speech naturalness
  • Stuttering severity (mild, moderate, severe) - about perception!!!
  • Speech rate - try to get out the sentence so they don't stutter
  • Linguistic complexity - can be manipulated (How old are you? - four… only one word utterances → not using full sentences)
  • Ask for interests to get a full narrative
  • Higher linguistic complexity - more demanding on the speaker
  • Lower linguistic complexity - less demanding on the speaker
  • Pattern analysis
  • What do they have the most?
  • blocks , repetitions, prolognations? - a combo?
  • Qualitative
  • Intonation
  • Loci of tension
  • Secondary symptoms
  • Consistency
  • Attitudes and feelings
  • Stimulability
  • Assessment can happen in different ways
  • home/school
  • Telephone
  • Reading
  • Video and audio  recording of play time w/ parents, siblings, grandparents
  • 350-500 syllables

Calms Model —>

  • Cognitive
  • Social
  • Affective
  • Motor
  • Linguistic

 

Differential Diagnosis

  • Stuttering-like disfluencies (SLD)

  • Consistent part-word & monosyllabic repetitions (<2)

  • Phoneme repetitions

  • Prolongations

  • Blocks

  • Revisions – Avoidance? Anticipation?

  • Pauses, interjections – Avoidance? Anticipation?

  • Tension

  • Escape behaviors

  • Secondary characteristics

  • Normal Disfluencies

  • Pauses

  • Interjections

  • Revisions

  • Part-word & monosyllabic repetitions are common in 2-4 yo

  • 4+ yrs old - better grasp of language and grammar

Assessing Frequency

  • Most common: percentage syllables stuttering (%SS)
  • %SS = total stutters/total syllables
  • When counting stutters, each syllable can only be stuttered once (e.g., N-n-n-n-n-nuh-nuh…[silent block]…name” = one stutter)
  • If client has obvious avoidance behavior without stutter, count as stutter (e.g., “My name is uh…uh…uh…uh…Barry.”)

Assessing Duration

  • Average 3 longest durations

Lecture 5: 10-4-22

Funneling -Start with discussion away from stuttering – too much emotionality involved

Funneling = get to know your client first before you address the “monster”

Interviewing

  • Spontaneity and flexibility
  • Openness, honesty, and trustworthiness
  • Concentration, self-awareness, and emotional stability
  • Belief in people’s ability to change and commitment to people
  • Good communication skills and academic/clinical competence

Cultural Considerations

  • Be culturally sensitive and develop a multicultural perspective on assessment

  • Issues that require sensitivity if client is from another culture:

  • Eye contact

  • Physical touch

  • Nature of reinforcers

  • Family interaction patterns

  • Intentional stuttering

  • Verbal and nonverbal communication styles

  • Care needed in using an interpreter

  • Multicultural and multilingual clients require careful analysis of stuttering in all languages

  • “Yesterday I-I-I-I, you see, I, well, um I-I-I-I was here”  repetition

  • “I want go to the……I want to watch a film”  word avoidance

vs.

  • “Oh…..26 times 20 is….um…520”  truly thinking
  • “he needs the will to live…the will to succeed”   slip of the tongue