PSYCH313 Fluency Disorders Notes

Fluency Disorders

Learning Outcomes

• Fluency disorders.
• Types of fluency disorders.
• Prevalence and characteristics.
• Potential causes.
• Factors.
• Assessment and treatments.

What are Fluency Disorders?

• Fluency disorders are speech disorders where a person has trouble with the natural flow of speech.
• Individuals often know what they want to say, but their speech doesn't come out easily or smoothly.

Fluency Comparison: Dimensions of Fluent Speech

• Continuity (Smoothness)
  • Speaking without sudden stops, blocks, or repeated words.
  • Example: "I went to the store…" instead of "I… uh… went… um… to… the store."
• Rate of Speech
  • How fast or slow someone speaks.
  • A natural pace is easy to follow, not too slow (tiring) or too fast (confusing).
• Rhythmic Structure
  • The natural rhythm and melody (intonation) in speech.
  • Example: "Are you coming?" (rising tone).
• Information Load
  • How much we say at once and how easy it is to understand.
  • Example: "I saw a man" (light load) vs. "I saw a man with a long beard wearing a black shirt…"
• Physical & Mental Effort
  • How much effort it takes to speak—mentally and physically.
  • Fluent speech feels easy; struggling is like lifting a heavy mental weight.
  • To understand fluency disorders, we must know what are different aspects that contribute to a person's ability to speak smoothly and effectively in a language.

Types of Fluency Disorders

• Stuttering: A fluency disorder where the normal flow of speech is disrupted by repeated sounds, syllables, or silent blocks, making speech feel tense or interrupted.
• Cluttering: A fluency disorder characterized by speech that is unusually fast, uneven, or jumbled, often making it difficult for listeners to understand.

Types of Stuttering

• Developmental Stuttering
  • Age of Onset: Around 3-4 years.
  • Causes: Natural speech development, typically during language acquisition.
  • Common in: 8% of 3-year-olds, 11% of 4-year-olds.
• Acquired Stuttering
  • Age of Onset: Adulthood.
  • Causes: Head injury, stroke, neurological disease, medication, trauma.
  • Common in: Adults, often following injury or trauma.

Prevalence of Stuttering

• Stuttering usually starts between ages 2 and 5, when kids are learning to talk quickly.
• About 5 to 8 out of every 100 children will stutter at some point during their early childhood.
• Around 80% of these children stop stuttering on their own without needing special help.
• About 1 in 100 children may continue to stutter as they grow older.
• In New Zealand, stuttering affects 1 out of every 100 adults.

Characteristics of Stuttering

• Primary Characteristics
• Secondary Characteristics

1. Primary Characteristics

• Repetitions
• Prolongations
• Interjections
• Blocked sounds/words
• Example symptoms can range in severity from mild to severe:
  • Repetition: may occur at the beginning of a word and be a single sound (e.g., "D-D-D-og") or a part of a word (e.g., "Cat-cat-cat-catastrophe")
  • Prolongations: occurs with a single sound (e.g., "SSSSS ay that again?")
  • Interjections: are filler words that are used when a person has difficulty moving from one word to the next (e.g., "I'll see you um um like um at 7:00 o'clock).
  • Blocked words: occurs when the mouth is positioned to say the word or part of a word, but the word is stopped, and no sound comes out. Blocks can last for several seconds.

2. Secondary Characteristics

• Signs of physical tension or facial expressions that indicate struggle during speaking.
• Examples:
  • Pursed lips
  • Eye blinks
  • Flapping arms
  • Facial tension
  • Abnormal head movements

What Causes Stuttering?

• Scientists don’t know the exact cause of stuttering, but many believe it’s linked to how the brain works, especially in the areas that control speech and language.
• Possible Reasons:
  • People who stutter may have slight differences in the parts of the brain that help with speaking and understanding language.
  • A head injury or brain damage (like from an accident or stroke) can cause someone to start stuttering, even if they never did before.
  • Some health problems that affect the brain, like Parkinson’s disease or epilepsy, can lead to stuttering.
  • Around 70% of people who stutter have a family member who also stutters, which suggests genes might play a big role.
  • Researchers believe it’s mostly due to neurological (brain-related) and genetic factors.

Factors Influencing Stuttering

• Internal Factors
• External Factors

Internal Factors

• Things happening inside the body or mind that can make stuttering more likely or worse, usually falling into two main areas:
  • Psychological Factors
    • Stress, anxiety, or feeling nervous, especially in social situations, can make stuttering worse.
    • Stuttering often increases when someone feels pressured to perform, like during a presentation or when speaking to strangers.
    • A sudden shock, whether emotional or physical, can sometimes trigger or worsen stuttering.
  • Cognitive Factors
    • Stuttering can happen when the brain has trouble controlling speech muscles or organizing words and sentences before speaking.
    • If someone thinks too fast or struggles to put their thoughts into words clearly, it can affect how smoothly they speak.

External Factors

• Things outside the person’s body, like surroundings, social situations, or family life, that can make stuttering more likely or more noticeable.
  • Social Factors
    • How people interact at home, school, or with friends can strongly affect someone who stutters.
    • Feeling insecure, having strict or harsh parents, or growing up in a tense home with lots of arguing can raise stress levels and impact fluency.
    • School pressure, especially from teasing or negative reactions, can make someone more self-conscious about speaking.
    • When a new baby is born, older children may feel left out or stressed, which can sometimes affect their speech.
  • Environmental Factors
    • Being in a noisy place, feeling rushed, or having to speak in a stressful situation can make stuttering worse.
    • If everyone talks very fast at home, a child may struggle to keep up, which can lead to stuttering.
    • If stuttering runs in the family, external stress can trigger or increase it.

Assessment

• Onset.
• Progressing.
• Receding.
• Problem in reading.
• Problem in conversation.
• Any specific situation.
• Any specific person.
• Name.
• Age.
• Gender.
• Address.
• Family history.
• Developmental milestone.
• Medical history.
• Presenting complains.

Types of Assessment

1. Stuttering Severity Instrument – Fourth Edition (SSI-4)
2. Real-Time and Offline Speech Sample Analysis
3. Dynamic Assessment (DA) of Fluency

1. Stuttering Severity Instrument – Fourth Edition (SSI-4)

• The SSI-4 is a standardized tool used by speech-language pathologists to measure how severe a person's stuttering is. It looks at three key things:
  • Frequency – How often does the person stutter?
  • Duration – How long does each stuttering moment last?
  • Physical Concomitants – What visible body movements happen during stuttering (e.g., eye blinking, head movement)?
• Why is it important?
  • It gives a score that helps speech therapists decide on the best treatment.
  • It works for children, teens, and adults.
  • It can be used in different places, like schools, clinics, or homes.

Components of SSI-4

1. FREQUENCY OF STUTTERING
2. DURATION OF STUTTERING
3. PHYSICAL CONCOMITANTS

Scoring:

• % Syllables Stuttered
  • 0 – 1% = Score 0
  • 2 – 3% = Score 2
  • 4 – 6% = Score 4
  • 7 – 9% = Score 6
  • 10 – 12% = Score 8
  • 13 – 15% = Score 10
  • 16 – 18% = Score 12
  • 19 – 21% = Score 14
  • 22 – 24% = Score 16
  • 25% or more = Score 18
• Average Duration (sec)
  • 0 – 0.5 = Score 2
  • 0.6 – 1.0 = Score 4
  • 1.1 – 1.5 = Score 6
  • 1.6 – 2.0 = Score 8
  • 2.1 – 2.5 = Score 10
  • 2.6 – 3.0 = Score 12
  • 3.1 – 3.5 = Score 14
  • 3.6 – 4.0 = Score 16
  • 4.1 or more = Score 18
• Behavior Severity Examples
  • None = No physical signs = Score 0
  • Mild = Brief eye blinking, slight tension = Score 4
  • Moderate = Head movement, facial grimacing = Score 8
  • Marked = Shoulder jerking, body tension = Score 12
  • Severe = Intense visible struggle = Score 16
  • Very Severe = Multiple behaviors with intense struggle = Score 20

Total Score and Severity Rating

• Total Score
  • 0 – 10 = Very Mild
  • 11 – 20 = Mild
  • 21 – 30 = Moderate
  • 31 – 40 = Severe
  • 41+ = Very Severe

Example

Let’s say a student named Zara reads the passage above, and her stuttering is observed as follows:

1. Frequency of Stuttering

   • Zara stuttered on 12 out of 100 syllables
   • 12% frequency = Score: 8

2. Duration of Stutters

   • Three longest stutters lasted 1.7s, 2.1s, and 2.0s
   • Average = $(1.7 + 2.1 + 2.0) ÷ 3 = 1.93$ seconds
   • Duration Score = 8

3. Physical Concomitants

   • Observed behaviors: eye blinking, lip tremor, slight head movement
   • Severity level: Moderate
   • Physical Score = 8

Final SSI-4 Score and Severity

• Component
  • Frequency (12%) = Score 8
  • Duration (avg. 1.93 sec) = Score 8
  • Physical Behaviors = Score 8
  • Total Score = 24
  • Severity Rating: Moderate

2. Real-Time and Offline Speech Sample Analysis

• Type: Clinical observation
• Description: Collecting and analysing speech samples in various contexts (e.g., structured, spontaneous, conversational) to identify types of disfluencies.
• Why it is relevant: Gives insight into how stuttering varies by situation.
• Latest practice: Often paired with video/audio analysis software to code disfluency types more efficiently.

Comparison: Real-Time Analysis vs. Offline Analysis

3. Dynamic Assessment (DA) of Fluency

• A way to check how a person’s stuttering changes in different speaking situations. Instead of just looking at how someone speaks once, this kind of assessment looks at how their speech responds to help or changes in the environment.
  • Type: Non-standardised, interaction-based
  • Description: Measures how the child responds to scaffolding, feedback, or fluency-enhancing strategies during real-time tasks.
  • Why it is relevant: Helps differentiate developmental stuttering from typical disfluencies or other speech issues.
  • Latest use: Increasingly used for early stuttering in younger children (ages 3–6) to guide treatment need.

Step-by-Step Method

• A method used to observe stuttering and see if using certain strategies can help improve fluency.
  • Step 1: Baseline Speech Sample
    • Ask the speaker: “Tell me about your favorite animal.”
    • Observe:
      • Does the person stutter?
      • What kinds of disfluencies are there? (Examples: Repetition, block, interjection)
    • Use a simple checklist to keep track.
  • Step 2: Introduce Fluency Strategies
    • Gently guide the speaker using these helpful techniques:
      • Slower speech: “Take your time, like this…”
      • Pacing: “Let’s tap gently on the table as we say each word.”
      • Choral reading: “Let’s say it together first.”
    • Then ask again: “Now can you try telling me about your favorite animal again?”
    • Observe again:
      • Is there less stuttering?
      • Does the speaker sound more confident or relaxed?

Dynamic Assessment (DA) of Fluency: What to Observe

Holistic Approach

1. Getting the full story

   • At the start of the therapy session, the speech therapist will ask for a detailed case history.
   • This means they’ll ask about:
     • When the stuttering started
     • How often it happens
     • Any family history (stuttering often runs in families, the child might be more likely to stutter)
   • Sometimes this part is done without the child, so adults can speak more openly.

2. Assessing the child’s speech

   • The therapist will then look at how the child talks and uses language.
     • With young children, this usually happens in a fun and relaxed way—through play and casual conversation.
     • This helps the child feel comfortable and not self-conscious about their speech.

3. Understanding what makes talking harder

   • By listening and observing, the therapist tries to spot things that might be making speech more difficult— like stress, fast talking, or pressure to speak.
   • They’ll also suggest practical ways to help, such as:
     • Slowing down when speaking
     • Taking more pauses
     • Creating a relaxed environment for communication
   • Since no one knows exactly what causes stuttering, it’s important to look at the whole picture, all the possible factors that might affect a child’s speech.

Treatment

• There are a variety of treatments available.
• The nature of the treatment will differ, based upon:
  • Person’s age
  • Communication goals
  • Severity
  • Causes

1. Fluency Shaping Therapy

• Also known as "speak more fluently", "prolonged speech" or "connected speech", trains stutterers to speak fluently by controlling their breathing, phonation, and articulation (lips, jaw, and tongue).
• It is based on operant conditioning techniques.
• How fluency techniques help stuttering
  • People who stutter are first taught to slow down their speech by:
    • Stretching out vowels and consonants
    • Using gentle sounds and continuous airflow
  • At first, their speech may sound very slow and flat, and it’s only used during practice in the clinic.
  • Once they get better at these skills, they slowly increase their speaking speed and expression.
  • Eventually, their fluent and more natural-sounding speech is used in everyday life.

2. Electronic Fluency Devices

• Help people who stutter by changing the way they hear their own voice. This is called altered auditory feedback (AAF), and it’s been used for over 50 years in stuttering treatment.
• How it works:
  • The device changes the timing or pitch of the speaker’s voice.
  • By blocking out the stutterer's voice while talking (masking)
  • When the person hears their voice differently (by adding a delay or echo), it can help them speak more smoothly.
• Examples of devices:
  • Delayed Auditory Feedback (DAF)
  • Frequency Altered Feedback (FAF)

3. Diaphragmatic Breathing

• Some stuttering treatments use this techniques (also called costal breathing) to help control stuttering.
• It’s a way of breathing that focuses on using the diaphragm, the muscle just below your lungs, to take deep, controlled breaths.
• When people stutter, they often breathe in a shallow or tense way. Using the diaphragm helps create steady airflow, which can make speaking smoother and more controlled.
• Singers often don’t stutter while singing, because singing requires voluntary diaphragm control. But during normal speaking, breathing is more automatic, and that’s when stuttering tends to happen.
• Learning to control your breathing like a singer can sometimes help with fluency!

Conclusion

• Collaboration is key when helping a child who stutters, as parents, teachers, and others must work together to support the child's speech and confidence.
  • Parents can share helpful info about how their child speaks at home and how they’re doing in therapy.
  • Teachers can support the child in class by giving them chances to practice speaking in a safe, encouraging way.
  • Everyone working together helps create a full, supportive plan to improve the child’s speech and overall confidence.

References

• Yairi, E., & Ambrose, N. G. (2013). Epidemiology of stuttering: 21st century advances. Journal of Fluency Disorders, $38(2)$, 66–87. https://doi.org/10.1016/j.jfludis.2012.11.002
• Reilly, S., Onslow, M., Packman, A., et al. (2013). Natural history of stuttering to 4 years of age: A prospective community-based study. Paediatrics, $132(3)$, 460–467. https://doi.org/10.1542/peds.2012-3067
• Bloodstein, O., & Ratner, N. B. (2008). A Handbook on Stuttering (6th ed.). Delmar Cengage Learning.
• http://www.nidcd.nih.gov/staticresources/health/voice/StutteringFactSheet.pdf
• http://my.clevelandclinic.org/disorders/Stuttering/hic_Stuttering.aspx
• http://www.asha.org/public/speech/disorders/stuttering.htm
• http://dspace.dial.pipex.com/town/plaza/aaq41/rwilliams/chap2.htm
• http://www.pakistanstammering.org/
• http://www.stammeringcurecentre.com/introduction.html