Fluency Disorders

Case study: Young man w/ stuttering

13 year old, began stuttering at age 13, stuttering would come and go, fluent periods that would last 2 months. severe stutterer, long sound prolongations twice a week for 6 months therapy. 10 months of therapy total, happy with speech.

Phase 1 of onset and dev:

2-6 years old, periods of stuttering are followed by periods of relative fluency. Periods of non-stuttering, will stutter most when upset or excited or communication pressure , sound and syllable repetitions dominate feature, also tendency to repeat whole words. Begining of sentences, clauses. content and function words. generally confined to content words. Child unaware of interruptions in speech or unbothered by them.

Case study of a child with stuttering: Tamara

4 yr old who has had trouble with first sound syllables at the beginning of each utterance. ex: "C-c-c-can I have some ice-cream" or Ba-ba-ba bassball is boring" . lasted about 2 weeks. disappeared for 6 months then reappeared. She was prolonging sounds "I-i-i want to sssssssit over there" Mother speaks fast and complex sentence structures. 15 instances of stuttering per 100 words spoken, frequently loose eye contact. Based on these findings it is recommended that tamara be seen in direct therapy two times per week. 4 months of direct intervention and perennial instruction, behaviors reduced. Mother learned to slow rate of speech.

The number of adults that have reported that they have stuttered at some point in their life is ..

5%

Efficacy of intervention with school age children

60% post treatment improvement with different treatment approches, another study 96% maintained fluent speech 14 months after treatment when enrolled in two treatment programs...61% average decrease in stuttering frequency

Percentage of children that will recover from stuttering within the first 2 years after its onset

65%-75% .....85% will recover within the next few years, 4 of 5 will recover. 5% lifetime incidence reduces down to 1% incidence.

Efficacy of all age groups

70% . preschool improving more quickly than others and those with a longer history of stuttering.

Phase 3 of onset dev

8 years- young adulthood, speaking to strangers, speaking in front of goups, or on the telephone, some words harder than othersCircumlocution used to avoid term, there will be little evidence of fear, embarrassment, or avoidance

Effects of stuttering through the lifespan

Almost always in early childhood, 68% of stutterers in 36 months, 95% of children by 48 months

Age of development/ developmental stuttering:

Any age, most common preschool years (developmental stuttering). Disfluencies usually content words ( nouns or verbs) frequently exhibit secondary characteristics and anxiety about speaking Clear differences in stuttering frequency across speaking tasks. Tends to occur on the initial syllables in words Improve with repeated readings or singing.

The EXPLAN model

Applies to both fluent speakers and speakers who stutter. Speech Planning (PLAN) is the linguistic prices of language formulation and execution (EX) is the motor activity related to production of the language formulation. Stuttering results from failure in normal interactions between plan and ex processes. Fluency failures occur when linguistic plans are sent too slowly to the motor system. EXPLAN: EX: motor activity (execute) PLAN: the linguistic process of language formulation Fluency failures are a result of a disruption in the communication between the two processes

Normal Disfluencies

At about 2 years old typical disfluencies:whole word repetitions( I-I-I want ) interjections ( can we um go) and syllable repetitions ( ba-baseball) 3yrs old revisions ( he can't- he won't play baseball) common. Normal fluencies persist through life, but don't tend to adversely affect the continuous forward flow of speech.

Fluent Speech

Consistent ability to move the speech production apparatus in an effortless, smooth and rapid manner resulting in a continuous, uninterrupted forward flow of speech.

Fluent Speech vs. stuttering

Flow of most children speech not continuously forward and interrupted. children exhibit hesitations, revisions, and interruptions. Children not born fluent speakers. Fluency requires some form of physical maturation and lang. experience.

Therapeutic techniques designed to modify stuttering behaviors are classified generally into two broad categories

Fluencey shopping techniques and stuttering modification techniques. Both have powerful effects of reducing stuttering.

Development of Fluent speech

Fluency doesn't develop linearly. 25 months are more fluent then they will be at 29 months and 37 months of age. There is a gradual increase in disfluent speech behaviors begging around 2 years of age and peaks around the third birthday. Fluency then improves at the age of 3 and the types of disfluencies change.

Familial incidence:

High, 50% of ppl who stutter report having a relative who stuttered at some time in his or her life. 15% of first-degree relatives of people who stutter are current or recovered stutterers. 5% lifetime prevalence is genetically significant.

Dr. Charles Van riper

Learned to control his stuttering and was on a quest for a cure

Behavioral techniques

Light articulatory contacts : reducing pressure when producing sounds, particularly during production of stop constants, used to reduce prolonged articulation postures hat interfer with smooth speech. Gentle voicing onsets (GVO) also known as FIGS ( fluency initiation of gestures) - tension free onset of voicing that gradually builts in intensity. Learned in hierarchy fashion, (vowel production, syllable production, and word productions)

clustered disfluencies

More than one tyoe of within-word disfluency may be present in a given disruption ex: m-m-m-mmmmmommy. common in children who stutter. May indicate the begging of stuttering (incipient stuttering)

Stuttered disfluencies

No universally accepted definition of stuttering exists. Ongoing speech behaviors are termed as disfluencies and the frequency, duration, type, severity define disfluencies. vary from person to person & situation.

Demands and capacities model

Stutter develops when the environmental demands placed on a child to produce fluent speech exceed the child's physical and learned capacities. The child's fluent speech depends on a balance of motor skills, language production skills, emotional maturity and cognitive development. Children who stutter presumable lack on or more of these capacities for fluent speech. Parents may ask for the child for rapid speech and expectations. DCM: imbalance betters the environmental demands and the child's capacity for fluent speech. Not a theory, but a tool used for understanding.

Efficacy of intervention with adolescents and adults

Teenagers difficult to manage clinically, adult therapy available though operant and drug therapy available 60%-80% improvement regardless of the therapeutic technique used.

Efficacy of intervention with preschool age children

The findings of most recent studies are quite encouraging and indicate the potential benefits of early diagnosis and treatment of stuttering. 91% of preschool children who had been in a treatment program maintianed their fluent speech 5 years after initial eval. All mainiantained speech 7 years after dismissal from treatment. 100% of 45 preschool-age children who stuttered had maintained fluent speech 2 years later.

Goal of therapy

To improve the daily life of people who stutter by increasing their ability to speak to whoever they want whenever they want

Therapeutic techniques used with young children: Evaluation of stuttering

Two important concepts: observations and parental interview. Primary component is the detailed analysis of childs speech behavior average # and type of disfluency used. Three or more within word disfluencies per 100 words words spoken may indicate that the child has a disfluency problem, percentage of each disfluency plays a role also. Stuttering prediction instrument yields a numerical score that is converted into a verbal stuttering severity rating. SLP will record secondary symptoms that the child presents, secondary symptoms may indicate a progression of the disorder.

Lidcombe program

a parent administered treatment in which positive reinforcement is provided to the child for stutter free speech. Highly effective for children ages 2-7. Child is asked to repeat the stuttered word correctly. praise and reinforcement is provided by parent five times more than corrections of stuttered speech.

Neurogenic stuttering

associated with neruological disease of trauma, differs from developmental stuttering in several ways. Disfluencies occur on function words (conjunctions and prepositions) don't exhibit anxiety or secondary characteristics while speaking. More widely dispersed in the utterance. No clear differences in stuttering frequency across speaking tasks. Stutterers do not improve with repeated readings or singing.

Stuttered speech involves

audiable or silent repettions or prolongtions, tense pauses and hesitations within and between words, with-in word and between word disfluenciess are believed to be the cardinal universal features of stuttering

The Covert Repair Hypothesis

based on language production model, assumes that stuttering is a reaction to some flaw in the speech production plan, people who stutter have poorly developed encoding skill shat cause them to introduce errors into their speech plan. Stuttering is a "normal" repair reaction to an abnormal phonetic plan.

Considered effective if

being able to speak with disfluencies within normal limits whenever and to whomever he or she chose, without undue concern or worry about speaking

stuttering modification

cancellation phase, pull-out phase, change overall behaviors.

Secondary Characteristics

concomitantly with disfluencies , also called accessory behaviors, are widely varied and idiosyncratic. - include: blinking, facial grimacing,facial tention, exaggerate movements of head, shoulders and arms. "interjected speech fragment" "this is to say" in the middle of sentence. Adopted behaviors in an effort to minimize behaviors. Trial and error bodily movements help terminate or avoid an instance of stuttering. Eye blinking looses ability to stop stutter and person forced to replace with new behavior. Blinking may remain perm. associated with stutter.

psychological theory

contends stuttering is a neurotic symptom, neurosis or phobic manifestation, psychotherapy is not effective treatment based on research

Selecting intervention techniques:

depends on many factors, severity, motivation and specific needs of individual. Careful observation and technique, one-size- fits all does not exist

Prevalence of stuttering

determined by ascertaining the number of cases in a given population during a given period of time. 0.97% for school aged children. Prevalence is stable from first-9th grade and declines in 10-12 grade

diagnosogenic theory

diagnosed by lay person( parents), begins in the parents ears, made anxious child about speaking, fostered further hesitations and repetitions, no evidence to support this, but evidence in the contrary to tell the child to slow down and start again.

Conditions that disrupt fluent speech

dysarthria, apraxia, cerebral palsy, and some forms of aphasia effect fluent speech

Phase 2 of onset and dev

elementary school, stuttering is chronic & habitual with few intervals of fluent speech, child will refer to them selves as a stutterer. Occurs on content words, less tendency to stutter only on the instial words of sentences and phrases. increases when excited

Gender differences

females appear to recover from stuttering more then males. Affects more males than females. Ratio: 2.3 to 1 and 3.0 to 1, attributed to the physical maturation rates of boys and girls and the differences in speech and language development, genetic factors may also be involved.

Stuttered speech differs from

fluent speech

indirect approaches

for children just beginning to stutter, provide slow relaxed speech model.Play-oriented activities. Enviornmental manipulation, no explicit discussion about the child's fluent or stuttering speaking behaviors.

direct approaches

for children stuttering at least a year, hard and easy speech. Hard: rapid and tense, ex: tense sssss sound in snake. Children taught to identify both types of speech. " easy and hard speech and teaching strategies are used to help use easy speech. Identification and modification used.

Cause and cure of stuttering

has not been discovered. Cause is elusive and understanding is incomplete, despite it's long and diverse history. Been a part of history since the beginning of time.

Computer simulation models

have been programed to stimulate stuttering, providing evidence for a disrupted speech motor control system in individuals who stutter.

5% incidence rate includes

high percentage of children who naturally recover from the disorder before the age of 6

Twins and stuttering

if one twin stutters, it is likely that the other will stutter as well. Rate of concordance is higher for monzygotic twins than for dizygotic twins (fraternal) twins.

Response contingent time-out from speaking

individual pauses briefly from speaking after a stuttering behavior, reduce stuttering to almost zero especially effective for young children who stutter and when parents use.

Developmental stuttering

influences the speakers ability to produce fluent speech. Stuttered speech is characterized by involuntary repetitions of sounds and syllables (b-b-ball), Sound prolongations (mmmmmmm-mommy) and broken words (b--oy)

Disflueincies that are likely to be regarded as stuttering include:

monosyllabic whole word repetitions ( he-he-he hit me ) sound repetitions (p-p-p-please) and syllable repetitions, ba-ba-baseball, audible prolongations (sssss-now) and inaudible prolongations

Why children naturally recover from stuttering

not understood

Developmental stuttering facts

occurs from ages 2-5, 75% of risk occur before child is 3 1/2. Onset gradual severity increasing as child grow older. Gradual trends seen. Not all children follow trend. Not always gradual. 4 phases of developmental framework . 36% of children have distinct and sudden event. Moderate or severe

Response -contingent stimulation RCS

powerful fluency shaping intervention used to reduce or eliminate stuttering, based on skinners operant conditioning. Association between behavior and stimulus that follows, response and consequences and thus determine future occurrence of behavior

Children stutterers vs non-stutterers

produce many more part-word repetitions and prolongations than do children considered to be non-stutterers. Children with average type and severity are non-stutterers. Also, perceptual threshold for stuttering.

fluency shaping techniques

prolonged speech, pausing, phrasing, slowing speech, change overall speech timing,

Organic Theory

proposes and actual physical cause, mind and body separate, muscles of tongue not following the brain, cerebral dominance: sending competing signals, bran images found functional and structural differences in the brains of adults with chronic developmental stuttering

parental counseling

provide information about stuttering, model slow, relaxed speech, spend one to one time, do not pressure child to talk

Stuttering is insensitive to

race, creed, color, intellect, and virtually any other attribute that could be used to distinguish one human being from another.

pausing/ phrasing

rate reduction technique has an effect on stuttering. used to lengthen naturally occurring pauses and to add pauses between other words and phrases. used to limit utterance length to 2-5 syllables gradual increase in length and complexity of utterance program

Stuttering modification techniques

react to stuttering calmly, Dr. Charles Van Riper, speech timing causes fluency breakdowns. Three techniques to modify speech timing and abnormal reactions to stuttering: cancellations, pull-outs and preparatory sets. introduced in sequential order: cancellation- individual is required to repeat the word that was stuttered and cause deliberately following the production of that stuttered word. Pauses for 3 seconds then reproduces stuttered word in slow motion. Once this goal is met Pull-out phase: modifies the stuttered word during the actual occurrence of the stuttering, involves slowing down the movements, when individual is proficient at this Preparatory sets: involve using slow motion speech that was learned in the first two phases, in anticipation to stuttering. Goal is to initiate word in a more fluent manner.

Normally fluent speakers interrupt the forward flow of speech by

repeating whole multisyllabic words ( I really, really want) interjectiong word or phrase ( he will, uhhhh, you know... not ) repeating phrase ( will you, will you) and revising a sentence ( she can't-she didn't do )

prolonged speech ( fluency shaping technique )

speech slowed involuntarily under delayed auditory feedback one of the most powerful ways to reduce or eliminate stuttering prolonged speech may be a specific therapeutic goal or may involve use of various techniques that serve to reduce speaking rate and fluency

cerebral dominance theory

structural and functional differences in brains of adults with chronic developmental stuttering

Within word disruptions are most apt to be classified or judged by listeners as

stuttering

Repetitions, sound prolongations, and broken words are

stuttering behaviors that have a negative impact on the speakers ability to produce fluent speech.

World health organization model and effects of stuttering

stuttering consisdeded to be a handicap (disadvantages due to audible and visible events of a persons stuttering) negative effect on a verity of daily activities. Avoid jobs, school, interactions. Negative impact on childs school performance, delayed about half a yer, more likely to be held back, more likely to be bullied. Negative impact on work life, quality of life effected, social maladjustments,

Behavioral theory

stuttering is a learned response to external conditions

Phase 4 of onset dev

stuttering is in its most advanced form, vivid and fearful anticipation, audible vocal tension and rising pitch

Genetic research

stuttering may be linked to a specific single gene, although the location and the nature of such a gene is unknown. Contented genetic research will ultimately play a role in our understanding of stuttering.

Delayed auditory feedback

used to reduce stuttering , speaker hears his speech after an instrmental delay of some finale period of time. used clinically to prolong speech speaking rates of 30-60 syllables per minute, taught to prolong syllables, but not pauses.