Fluency Final Exam

What is an example of a Tense pause

"Can I have some more (lips together, no sound) milk?"

What is an example of an Interjection

"He went to the...uh...circus"

What is an example of a Revision-incomplete phrase

"I lost my...where's Mommy going?"

What is an example of a Single-syllable word repetition

"I...I want that"

What is an example of a Multisyllabic word repetition

"Lassie...Lassie is a good dog"

What is an example of a Part-word repetition?

"mi-milk"

What are some assessments that can be used for feelings and attitudes for adolescents and adults?

*Adolescents and Adults:* -Modified Erickson Scale of Communication Attitudes (S-24) has been normed on stutterers and nonstutterers (a) assess attitudes before and immediately after treatment (b) a lack of change in this score during treatment may predict relapse -Stutterer's Self-Rating of Reactions to Speaking Situations (SSRSS) (a) may predict relapse after fluency-shaping treatment

Why are some underlying processes of intermediate stuttering at ages 6 to 13 years?

*Classical conditioning* creates more and more tension in stuttering in more situations *Instrumental conditioning* creates a more complex array of escape behaviors *Avoidance conditioning* creates extra sounds and behaviors before the feared word and causes child to avoid more and more words and situations

What is intrarater vs interrator reliability?

*Intrarater reliability:* Reliability first demonstrated by showing that a rater makes same judgment when he or she judges behavior a second time (same rater) *Interrater reliability:* Reliability then demonstrated by showing that a different rater makes the same judgment as the first (different rater)

What are the developmental/treatment levels of dysfluency?

*Normal disfluency* *(1.5 - 6 years)* - although a small amount of normal disfluency continues in mature speech *Younger preschoolers - Borderline Stuttering* *(1.5 - 3 years)* *Older preschoolers - Beginning Stuttering* *(3.5 - 6 years)* *School-age - Intermediate Stuttering* *(6 - 13 years)* *Older Teens and Adults - Advanced Stuttering* *(14 years and above)*

What are some assessments that can be used for feelings and attitudes for preschool children?

*Preschool Children:* -KiddyCAT (Vanryckeghem, 2002) -Behavioral Style Questionnaire -Impact of Stuttering on Preschoolers and Parents

What are some assessments that can be for feelings and attitudes for School-Age children?

*School-Age Children* -A-19 Scale -Communication Attitude Test (CAT) - has been extensively researched and has shown good inter-item and test-retest reliability -Teachers Assessment of Student Communicative Competence (TASCC) (a) 50-item questionnaire to assess how well child communicates in classroom (b) shown to have high internal consistency

What ranges constitute typical, borderline and beginning disfluency?

*Typical disfluency:* >10 disfluencies per 100 words; multisyllable word and phrase repetitions; >3 iterations in reps that are slow and regular temple; child unaware *Borderline:* More than 10 disfluencies per 100 words; part-word and whole-word repetitions; more than two iterations in many repetitions *Beginning:* Tension and hurry in stuttering; awareness and frustration; escape behaviors; possibly some avoidance

What is classical conditioning?

- Begins with two things that are naturally associate -Then a neutral stimulus is added -After repeated associations, previously neutral stimulus elicits response

What information should you gather from the student interview for school age children?

- Get to know student first - his likes, dislikes, family, etc. - Discuss stuttering in a direct but accepting manner (a) Explore when he stutters the most, least (b) What he does when he stutters (have him teach you) (c) His feelings about his speaking (d) Others' reactions, teasing, parents' responses Avoidances

What does the stuttering severity instrument-3 (SSI-3) assess?

-*Frequency* assessed as percentage of syllable stuttered -*Duration* assessed as average of three longest stutters -*Secondary behaviors* assessed as ratings of four types of physical concomitants -Scores from these three components are summed to produce total overall score -SSI-3 percentile and severity scores based on total overall score -For preschoolers, school children, and adults

What are some congenital and early childhood factors related to stuttering?

-40 to 70 percent of stutterers have no family history of stuttering -Stuttering has been associated with: (a) brain injury before or soon after birth (b) premature birth (c) surgery (d) head injury (e) mental retardation (f) intense fear

What has research discovered about physiological tremors?

-A number of researchers (Fibiger, 1971; Smith, 1989; Van Riper, 1982) conclude that tremors are an important element in more advanced stuttering -Kelly, Smith, and Goffman (1995) found tremors in older children who stuttered, but not younger children -They further suggested that tremors may be evoked or amplified by emotion -Thus, tremors may develop when speech or stuttering is associated with emotion. This may occur when stuttering has been associated with fear, embarrassment, or other negative emotions

When do part-word repetitions normally stop and when is it an indicator of stuttering?

-After age 4, typical children show decrease in part-word repetitions If child is showing plateau or increase in part-word repetitions after 4, more likely to be stuttering

What factors should be addressed after assessment of school-age children in a school setting?

-After evaluation, clinician writes brief report in lay terms -Report should discuss affective, behavioral, and cognitive aspects of student's stuttering and school performance -IEP team meets to consider the severity of child's stuttering and its impact on education including extracurricular activities (a) Does student participate fully in school activities, or does stuttering limit him or her? (b) Can student meet school's curriculum objectives, especially those related to speaking? -If IEP team determines child is eligible, measurable goals and short-term objectives are developed -Services to meet these goals and objectives are determined

What changes in the brain occurred after therapy?

-After therapy, right brain overactivations are reduced -Left brain speech, language and auditory areas are more activated -Two years after therapy, some right brain overactivation has returned

How does primary stuttering (caused by anomalous neural networks) interact with environmental factors?

-An environment that is slow-paced and accepting may be more likely to give children freedom to develop fluency at their own pace -An environment that is fast-paced and demanding may be more likely to delay recovery

What should you analyze in a speech sample of someone who may clutter?

-Analyze to determine speech rate in syllables per minute. -Client's ability to slow down his rate while speaking is a good prognostic indicator since most of therapy is to slow down the speaker's rate of speech. -How frequent are the bursts? (The average person speaks in conversation at six to seven syllables per second)

What does the theory, which relates stuttering as a multifactorial dynamic disorder, by Anne Smith and her colleagues hold?

-Anne Smith and her colleagues (e.g., Smith & Kelly, 1997) suggest there is no one cause of stuttering, but an array of factors contributing to it -The problem is to find the relevant factors and discover how they interact -They see stuttering as "dynamic" because behaviors (repetitions, prolongations, blocks) are only surface features of an ever-changing process -Examples of the underlying factors are linguistic load, speech motor instability, emotional stress, etc.

How does primary stuttering interact with social-emotional development?

-As social-emotional development creates stress on children, those with more inhibited temperaments may be more likely to have more negative reactions to difficulty with speech -Children who manifest primary stuttering may develop secondary stuttering as social-emotional pressures increase (e.g., beginning school)

How do you assess severity?

-Assessment of severity is a clinically relevant measure because it captures what listeners experience -Good for measuring progress in treatments that reduce abnormality of stuttering but don't eliminate stuttering altogether -Three instruments to assess severity (on the following slides, SSI-3 is used in place of SSI-4, but SSI-4 is preferable

What are some consideration for treatment of cluttering?

-Because clients who clutter are usually not aware of their problem and are often surprised when listeners don't understand them, they rarely seek treatment. -Those who seek treatment are often referred by someone else -Two positive prognostic signs are: 1. The ability to speak without cluttering if asked to do so and 2. A specific reason for improving, such as keeping a job or receiving a promotion. -Children who clutter can often be engaged in games and activities that will create motivation for their work in treatment.

Given what we know about sensory and motor factors related to stuttering, what are some clinical implications?

-Because they process more slowly, slower speech may facilitate fluency -Because of sensory processing deficits, masking, and DAF, attention to kinesthetic feedback may be helpful in treatment

What should be included in the assessment interview for adolescents and adults?

-Begin by letting client know what will take place in the evaluation -Ask open-ended question like "Why don't you begin by telling me about your stuttering?" -After client has finished an initial description of concerns, ask about onset, development, and early experiences -Ask about current stuttering and how it affects social, occupational, and academic situations -Explore feelings - use results of questionnaires (S-24, etc.) as a basis to explore further -Explore client's awareness of current stuttering including escape and avoidance behaviors -Does client have questions?

Describe normal disfluencies between 2 and 5 years?

-Between 2 and 5, most children have normal repetitions, prolongations, and pauses -Repetitions are more common in younger children; revisions are more common in older children -Normally disfluent children don't react to their disfluencies; they seem unaware of them Normal disfluency characterized by: 1. No more than 10 disfluencies per 100 words 2. Typically one-unit repetitions, occasionally two 3. Most common disfluency types are interjections, revisions, and word repetitions. As children mature past age 3, they will show a decline in part word repetitions

What should be included in a case history and interview for a person who clutters?

-Case History -Where and When the Problem Appears -Background on individual and family -Reasons for seeking treatment at this time -A major determiner of success in therapy is the client's motivation -Other problems

How does primary stuttering interact with speech and language development?

-Child with primary stuttering may be able to recover if speech and language demands are low or language ability is strong -Another child with primary stuttering may not recover so easily if language development demands are high or child is not strong in speech and language

What stressful life events may precipitate or worsen stuttering in some children?

-Child's family moves -Child's parents divorce -A family member dies -A family member is hospitalized -The child is hospitalized -A parent loses his or her job -An additional person comes to live in the house -One or more parents go away frequently or for a long period of time -Holidays or visits occur which cause a change in routine, excitement or anxiety -A discipline problem involving the child

What are some developmental factors related to stuttering?

-Children must deal with limited neural resources handling a multitude of tasks -Motor and cognitive development compete for cerebral resources -Rapid developmental changes in the vocal tract stress the development of speech -Stuttering occurs when children are developing most rapidly during their preschool years

What should be included in a preassessment for adolescents and adults?

-Clinic versus school assessment -This evaluation described as though it is in a clinic When evaluation is in school, IEP process is followed -IEP process gets input from students when they are 14 or older and eventually involves not only school-based treatment, but transition plans as well -Case history form sent to adults several weeks prior to evaluation -Adolescents in school can fill out themselves with help from parents

Given what we know about stuttering and language, what is the clinical implication?

-Clinical implication: decreasing linguistic load on children starting to stutter may improve fluency

What are some other disorders similar to stuttering?

-Cluttering -Neurogenic speech disorders

What is cluttering?

-Cluttering often co-occurs with stuttering. -Cluttering is a disorder with probably neurological etiology. -It isn't viewed as a problem until a child has reached school age.

How do you assess duration of stuttering?

-Common practice is to average duration of three longest stutters -This is a component of severity assessment -Use stopwatch to measure duration (to nearest one-half second of longer stutters in sample). -Average longest three. The SSI-4 has software that allows easy assessment of mean duration of three longest stutters

What are some stressful speaking situations for children?

-Competition for speaking -Hurried when speaking -Frequent interruptions -Frequent questions -Demand for display speech -Excited when speaking -Loss of listener attention -Many things to say

What should be included in an interview with the family of adolescents?

-Convey sincere acceptance of family's viewpoint and concerns -Give family opportunity to express their concerns and emotions and to get their view of the adolescent's stuttering -Give some time for adolescent to express views and feelings privately -In closing interview with adolescent and family, give principle role in treatment to adolescent, but involve family as much as adolescent is comfortable with

What evidence do we have about stuttering as it develops?

-Course of development of stuttering may be in part determined by development of emotional reactivity, changing environmental situations, and changing internal and external speech and language production demands

What should be discussed in the closing interview for preschool age children?

-Describe positive aspects of child and parents' response to stuttering -Describe stuttering in appropriate, clear terms -Discuss treatment options -Respond to questions and implied concerns

What is the test of childhood stuttering?

-Designed for children between the ages of 4 and 12 years -Consists of three subparts: 1. Speech fluency measure made in several different linguistic contexts 2. Observation measure used by clinician, teacher, or caregiver 3. Supplemental clinical assessment used for a more detailed analysis of child's stuttering

What are the caveats related to brain differences findings?

-Differences between stutterers and non-stutterers may be a *result* of stuttering, not a cause -Findings may be inconsistent: (a) may be sub groups of stutterers (b) methods of research may differ between studies of same phenomenon

How is emotion related to stuttering?

-Emotion may increase stuttering and stuttering may increase emotion -Stutterers are not more anxious than non-stutterers, but more anxiety produces more stuttering -Autonomic arousal (activation of sympathetic nervous system usually caused by anxiety) is associated with stuttering -Stutterers may have more inhibited temperaments and may be more emotionally conditionable

What are social and emotional developmental factors related to stuttering?

-Emotional arousal increases stuttering and normal disfluency -Emotional stress during childhood may trigger or worsen stuttering -Some children who stutter -because of a sensitive temperament- may be more vulnerable to normal stresses of childhood. -Individuals who stutter appear to be normal in terms of psychocosial traits

How do environmental factors relate to stuttering?

-Environmental factors may interact with developmental factors to trigger or worsen stuttering

What should be considered regarding the client's right to privacy?

-Establish trusting relationship by acting to protect client's privacy -Be sensitive to what client may not want shared (This includes what children may or may not want shared with a parent) -Health Insurance Portability and Accountability Act (HIPAA) provides guidelines for protecting client's privacy and securing permissions

Why does primary stuttering occur?

-Evidence reviewed in Chapters 2 and 3 suggests that stuttering often emerges from deficits in left-hemisphere processing for speech and language -Such deficits may result in primary stuttering because neural circuits for speech and language may be: (a) Working in an "underdeveloped" area (b) Reorganized and moved to an area not naturally suited to rapid speech and language functions (e.g., right hemisphere) (c) Reorganized so that major functions are at some distance from each other (d)Slower in processing because of less dense pathways

How does Secondary stuttering (cased by reactive temperament) interact with environmental factors?

-Families can help reactive child develop skills to manage stress, thus decreasing likelihood of stuttering becoming persistent -Some life events (e.g., divorce, hospitalization) can increase vulnerable children's reactivity, thus increasing likelihood of stuttering becoming persistent

What are some feelings/attitudes associated with stuttering?

-Feelings can be as much a part of the stuttering as the stuttering behavior -Feeling can precipitate the stutter -Fear of stuttering, guilt of not being able to help ones self and hostility toward the listener can occur -People that stutter can be tense, insecure and fearful

What should be included in the closing interview with adolescents and adults?

-Focus on positive aspects first -Describe stuttering behaviors, feelings, and attitudes, and provide explanation as far as possible -Describe therapy options, and give recommendations -Provide client with assignments to start -Set up next appointment if appropriate

What are some guidelines for obtaining a speech sample?

-For assessment, attain two samples: one in clinic and one outside -Outside samples: (a) Preschoolers: at home (b) School-age: in school (c) Adolescents and adults: at work or in a phone conversation -Because stuttering is variable, ensure that sample is representative of current level of stuttering -Videotaping is important for major samples

What should be done prior to closing interview (interview with parent before the start of treatment) with preschool age children?

-Gather information from various sources, such as home video, case history, interview, observations of child's stuttering, clinic video. -Develop hypothesis about: (a) Child's current developmental/treatment level (b) Important risk factors (c) Treatment approach

How are genes related to stuttering?

-Genes are associated with stuttering and have been found on chromosomes 1, 7, 9, 12, 13, 15, 16 and 18 -Persistent and recovered stuttering is associated with chromosome 9; persistent stuttering is only associated with chromosome 15 -Studies in different cultural groups have identified chromosome 12 as significantly related to stuttering -Mutations of 3 different genes on chromosome 12 have been associated with stuttering

What does Geschwind & Galaburda's theory propose?

-Geschwind & Galaburda (1985): left-hemisphere delay, right-hemisphere dominance --> inefficient for speech = stuttering

What recommendations would you provide to parents of children with normal disfluency?

-Give information about normal disfluency -If parents are concerned, set up another appointment in several weeks to reevaluate if disfluency persists or worsens -If needed, recommend changes in environment that may help all children: e.g., turn-taking, careful listening, appropriate speech rates

What is operant conditioning?

-If behavior is followed by reward, it increases For example: Parent says "good talking" after five fluent sentences --> child's fluency will increase If behavior is followed by punishment, it decreases For example: Parent says "Can you say 'truck' again?" after child stutters --> child's stuttering will decrease

How do we know if a child is displaying normal disfluencies vs. stuttering?

-If child has more than 50 percent stutter-like disfluencies, more likely to be stuttering than normally disfluent -If child has more than ten stutter-like disfluencies per 100 words, more likely to be stuttering

What are some public school considerations with school age children?

-Individuals with Disabilities Education Act (IDEA) and state laws set procedures for evaluation and treatment of students who stutter -When child is referred for stuttering, SLP makes discreet observation in classroom; confers with teacher and special education administrator -Child's parents are contacted, permission for an evaluation is obtained, and evaluation is carried out -Team of SLP, teacher, special education administrator, and parents discuss treatment options

What are some cognitive-developmental factors related to stuttering?

-Intensive cognitive development may compete with fluency -The "ups" and "downs" in a child's fluency may reflect spurts of cognitive development -After age 3, children may be self-conscious enough to have negative emotions about stuttering

What does Kent's theory hold?

-Kent (1994): deficit in central timing that regulates speech production and integrates left-brain segmental and right-brain supra-segmental aspects of speech production; this deficit produces stuttering

What information should you gather from parent interview for school-age children?

-Let parents know you support them and their child -Fill in gaps from case history (see section on areas to discuss with parents of preschool child) -Ask about how stuttering affects student in school (e.g., participating, teasing, teacher responses, etc.) -Try to determine if there are factors that would hinder recovery (e.g., parent's anxiety or negative attitude about stuttering, student's sensitivity, motivation, etc.) -Convey acceptance of family; comment on positive things they have done

How do you assess secondary behaviors?

-Major division = escape versus avoidance behaviors -*Escape behaviors* occur after stutter has started. They are an attempt to stop stutter and produce a word (ex. Head nod, eye blink) -*Avoidance behaviors* occur before stutter has begun. They are attempts to keep from stuttering (ex. Saying extra sound, changing word) -Severity assessments often include measure of secondary behaviors

What information should you gather from the teacher interview for school-age children?

-Make an alliance with the teacher -Find out about child's communication in class, if stuttering interferes with communication, how teacher responds to child's stuttering, and if other children tease child about his stuttering -What information might you want to give to the teacher about stuttering? -Classroom observation: (a) Arrange a time with teacher to unobtrusively observe student when he may be talking in class (b) Note how much he talks, to what extent he avoids, and how others react to his stuttering

Any of the aforementioned arrangements may make these circuits both inefficient and vulnerable to disruption. How does this inefficiency lead to primary stuttering?

-Many existing theories suggest dyssynchrony, at some level, is responsible for repetitions, prolongations, or blocks (e.g., Kent, 1984; Perkins, Kent, & Curlee, 1991; Webster, 1997; Van Riper, 1982) -Dyssynchrony may mean that units for rapid speech and language production are not assembled accurately or rapidly enough -Repetitions may result from repeated utterance of unit that is ready, while waiting for next (transitional) element that is not ready -Prolongations may result from maintaining voice or airflow of first unit while waiting for next (transitional) element that is not ready -Blocks may result from attempt to go ahead despite next (transitional) element not being ready

What evidence do we have about ameliorating conditions, which reduce or eliminate stuttering?

-Many of these conditions provide increased time or external stimulus which could help the brain coordinate the components of speech and language production (e.g., singing, speaking in time to a metronome) -Some conditions may create an environment in which the stutterer's nervous system is less reactive and hence secondary reactions to expectations of stuttering are less (e.g., speaking when alone, speaking to a child, speaking when relaxed)

How do you assess types of stutters?

-May be important in distinguishing normally disfluent children from those who stutter -Stutter-like versus normal disfluencies: (a) *Stutter-like* = part-word and single-syllable whole-word repetitions, tense pauses, and dysrhythmic phonations (b) *Normal* = multisyllable word repetitions, phrase repetitions, interjections, and revisions

What behaviors might you see in someone who clutters?

-May produce fillers -Incomplete phrases -Word and phrase repetitions -Revisions -Hesitations without tension -Sudden impulsive bursts -Filled with misarticulations

Given what we know about primary and secondary stuttering, what are some implications for treatment?

-Models of speech and language with slow rate and pausing may facilitate fluency in child with primary stuttering (Guitar et al., 1992) -Families can encourage less inhibited temperament by encouraging approach behaviors (Calkins & Fox, 1994) -Fluency skills-oriented therapies appear to reorganize networks for speech and language production (De Nil et al., 2003; Neumann et al., 2005)

What is the scale for rating the severity of stuttering and how is it different from SSI-3?

-More subjective than SSI-3 -Originally used for ratings by a group of listeners -Can be used to get overall clinical impression of client

How do you assess frequency of stutters?

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

Given what we know about stuttering and genes, what are some clinical implications?

-New research may lead to early identification and prevention. -This research shows that parents' behavior does not cause stuttering -Parents who are concerned about passing on stuttering genes should know that they pass on many desirable traits as well

How is brain structure and function related to stuttering?

-No matter what the etiology of stuttering, brain structure and/or function would be affected -Early EEG showed more right-brain activity during speech compared to non-stutterers -Early studies showed activity during speech shifted to left brain after treatment -Brain imaging studies show: (a) overactivation of several right hemisphere areas during speech (b) deactivation of left auditory cortex during stuttering (c) anomalous symmetry of planum temporale

What are some experiences that may make children believe that speaking is difficult?

-Normal disfluencies criticized by significant listeners -Delay in speech or language development -Speech or language disorders, including articulation problems, word-finding difficulty, cerebral palsy and voice problems -Difficult or traumatic experience reading aloud in school -Cluttering, especially if listeners frequently say "slow down" or "what?" -Emotionally traumatic events during which the child tries to speak

What are other concerns that should be considered for school-age children?

-Observe articulation and language; test if needed -Physical: Are there motor problems? Delay? -Cognitive: Learning disability? Attention/activity problem? Intelligence? -Social-emotional: Able to make friends? Highly sensitive or anxious? -Academic adjustment: Academic performance problems? Reading problems?

How do you obtain reliability using the percent error method?

-Obtain absolute differences between first and second rating of each item -Sum absolute differences to get total -Divide total by number of items to get average -Divide this average by average of first rating Ex: You test four items - and rate each twice Find the differences between each rating - you should have four Add the differences together and divide by four to get the average - Then, divide the average of the differences by the average of the first four assessments you performed

How do you obtain an overall score/percentile with SSI 3?

-Obtain scores for frequency, duration and secondary behaviors -Scores from these three components are summed to produce total overall score -SSI-3 percentile and severity scores based on total overall score -For preschoolers, school children, and adults

What did Oliver Bloodstein's theory, related to communicative failure and anticipatory struggle, propose?

-Oliver Bloodstein (1987; 1997) proposed that in many cases, stuttering begins when a child finds talking difficult -Anticipated difficulty in talking produces tension and fragmentation of speech -This leads to more frustration and failure in communication, which increases anticipation of difficulty

Evidence about the onset of stuttering continued.

-On rare occasions, onset is characterized by tension, struggle, and avoidance; this may occur in children whose temperament is more reactive -The characteristics of stuttering: repetitions, prolongations, and blocks may be the result of attempting to push ahead with speech production despite the fact that some required components are not ready in a timely fashion

What evidence do we have about the onset of stuttering?

-Onset occurs beyond the one-word stage, when more complex sentences are being produced -This may be the case because the anomalous, inefficient neural networks for speech and language are not taxed to the breaking point by single words; however, complex utterances require the time-dependent integration of phonology, syntax, semantics, and prosody, which may stress the system

What does Orton & Travis' theory propose?

-Orton & Travis (1931): lack of hemispheric dominance leads to mistiming of muscle activation = stuttering

Describe the severity rating scale for parents of preschoolers?

-Parents mark an "x" in relevant box at end of each day to indicate severity of stuttering for day -Weekly charts are used by parents and clinical to assess child's progress

What are other speech and language behaviors that should be considered during assessment of preschool age children?

-Parents reports and observations of child's speech and language may reveal other problems -Formal tests for phonological or language problems may indicate need for treatment concurrent with or following stuttering treatment -Compare syntax with vocabulary scores; disparity may be of concern -Also observe speech-motor and other fine motor skills -Hoarse voice may indicate laryngeal tension associated with stuttering

Given what we know about hereditary factors of stuttering, when are some clinical implications?

-Parents should be told that stuttering is often inherited, not the result of bad parenting. -The prognosis of a natural recovery is related to a number of recovery factors.

Other than fluency, speech, and language, what other factors should be considered during assessment of preschool age children?

-Physical development -Cognitive development -Social-emotional development -Speech and language environment

Are there two (or more) predispositions for stuttering?

-Primary stuttering may be the result of an anomalous organization of speech and language networks in the brain, which can resolve via maturation or reorganization -Secondary stuttering may be the result of additional factors - perhaps a predisposition for a reactive temperament -Some support for the existence of two predispositions come from genetic research -Persistent and recovered stutterers have similar genetic makeup; it is possible that persistent stutterers have some additional genetic predisposition

How might adult speech models cause stress for vulnerable children?

-Rapid speech rate -Complex syntax -Polysyllabic vocabulary -Use of two languages in home

How might a child "outgrow" borderline stuttering?

-Resource reallocation to compensate -Speech and language systems mature -Conflicts resolve

Sample guidelines continued.

-Samples must be long enough to get representative sampling of speech -For major assessments, use 300-400 syllables for conversation and 200 for reading -For reading sample, ensure passage is at or below client's level -Helpful for assessment of reliability to make transcript of conversation sample without stutters marked

How do we assess speaking or reading rate?

-Severe stutterers may produce speech at a very slow rate, decreasing their communicative effectiveness -Individuals who both stutter and clutter may have excessively fast rates of speech, making them somewhat unintelligible -Common practice to assess client's speaking and reading rates in terms of syllables per second -Speaking rate can be assessed using stopwatch and counter or various computer-based or handheld devices -Reading rates can be assessed by timing a client's reading of a standard passage of known syllable length

What does the capacities and demands theory by Sheehan (1970, 1975); Andrews et al. (1982); and Starkweather (1987) hold?

-Sheehan (1970, 1975); Andrews et al. (1982); and Starkweather (1987): stuttering may emerge when child's capacities for fluency are overwhelmed by demands Examples: -Capacities: Child's ability to plan and program for language while making fast, coordinated movements for speech -Demands: Some children's advanced conceptual and linguistic abilities; models of rapid and complex speech and language in environment; emotional stress on child from environment

Why does secondary stuttering occur?

-Some children who begin to stutter may have more "reactive" temperaments -This reactivity may cause them to respond to unpleasant or threatening stimuli by increasing tension, speeding up, escaping, and/or avoiding (cf. Gray, 1987, re: behavioral inhibition) -These reactions may constitute the components of secondary stuttering (i.e., increased tension, escape, and avoidance) -These temperament traits may be (like the predisposition to primary stuttering) the result of inheritance or brain injury -Because a reactive temperament causes emotional arousal, events that caused the emotion will be more deeply learned (learning is enhanced by emotion)

How is cluttering related to stuttering? Do they co-occur?

-Some have cluttering and stuttering in their speech production, but one usually dominates. -Cluttering is a central language imbalance suggesting that language deficits are at its core. -Cluttering usually most often co-occurs with stuttering. -Cluttering and stuttering are related, but no one has made a scientific conclusion yet of how they are related.

How does primary stuttering interact with brain maturation?

-Some individuals will recover early because they have greater neural plasticity -Females appear to have greater organizational plasticity and more widely distributed language centers

What is speech naturalness and how does is relate to assessment and treatment?

-Some treatments produce fluency, but clients don't sound natural -Clinical research has shown that both untrained and trained listeners can reliably rate speakers on a nine-point scale of "naturalness" (Martin, Haroldson, & Triden, 1984)

What other behavior might a person who clutters have?

-Someone who clutters may also have language learning problems. (Weiss calls it a Central Language Imbalance) -Can't seem to get his thoughts together in coherent sentences and link sentences in a thoughtful, meaningful way. -Such language behavior is termed "mazing" -*Mazing* is a metaphor for repeated false starts, hesitations, and revisions that leave listeners puzzled about a speaker's verbal destination.

What do we know about hereditary factors and stuttering?

-Stuttering appears to be inherited -There is a single gene for transitory stuttering; two or more genes for chronic stuttering

What do the current facts about stuttering imply?

-Stuttering is an inherited or congenital disorder -It first appears when children are learning the complex coordinations of spoken language -It emerges in those children whose speech production system is vulnerable to disruption by competing demands of language, cognition and emotion -After it emerges, it becomes persistent in come children - perhaps those whose stuttering arouses substantial negative emotion which leads to a variety of learned behaviors

How is stuttering related to language?

-Stuttering onset is sometimes associated with rapid language development -Stuttering is more likely with more linguistically complex utterances -More linguistically complex stimuli result in poorer sensory and sensory-motor tasks

Developmental factors related to stuttering continued.

-Stuttering seems to have its most frequent onset when the child is mastering more complex language -children predisposed to stuttering may have deficits in areas responsible for speech and language -Rapid speech and language development may stress these weak areas, resulting in stuttering -Some children may develop stuttering as a response to extra difficulty because of a speech or language delay and the stress it puts on speech production

What does cluttering consist of?

-Sudden bursts of rapid speech that is difficult to understand and somewhat disfluent -May have excess of normal disfluencies or co-occur with developmental stuttering -With effort and attention, speaker may be able to speak without cluttering -Cluttering often accompanied by disorganized language (mazing) as well as learning and neuropsychological problems

Given what we know about congenital and early childhood factors, what are some clinical implications?

-The clinician should explore the child's early health history and events surrounding the onset of stuttering -The clinician should be aware that one purpose of determining factors associated with stuttering is to relieve parents' guilt

Describe the role of the clinician's expertise in assessing and treating.

-The clinician's expertise will reassure the client and engender trust -The clinician acquires expertise by reading, experience, and intuition -The clinician reflects her expertise to the client through her: (a) Empathic comments (b) Display of comfort with stuttering and its associated emotions (c) Effectiveness in conducting evaluation

Given what we know about hereditary and environmental factors of stuttering, what are some clinical implications.

-The environment should be made as fluency-facilitating as possible. -The fact that a relative has persistent stuttering does not assure that stuttering will occur

How does stuttering differ in preschool children?

-The location and frequency of stutters is different in preschool children -Stuttering in preschool children occurs most frequently on pronouns and conjunctions (which are typically at the beginning of utterances in young children) -Stuttering most frequently occurs as repetitions of parts of words and single-syllable words in sentence-initial position -In summary, because stuttering in preschool tends to occur at the beginning of syntactic units, the trigger seems to be linguistic planning and preparation

What areas of the brain were different (or less dense) in people who stutter?

-There are less dense fibers in *white matter tracts of left operculum.* These fibers are thought to connect sensory planning and motor areas for speech. -The *superior longitudinal fasciclus* is also less dense in the left hemispheres of stutterers. This is bidirectional pathway between sensory integration and motor planning areas.

Given what we know about the brain, what are some clinical implications?

-There is evidence that treatment changes neurological function -This may suggest that treatment restores effective sensory-motor control of speech -More research is needed on brain changes that occur with effective vs. ineffective treatment.

How are parents an environmental factor for stuttering?

-There is mixed researched about whether parents of stutterers are more anxious -Children with vulnerable temperament may have inherited it from one or both parents, thus, parents may be perfectionistic, anxious, etc. -Research is unclear about whether kids who stutter have stressful speech and language models

Why secondary stuttering occurs continued.

-Therefore, children who react to primary stuttering with increased tension, escape, and avoidance behaviors will be more likely to continue these secondary behaviors long term (cf. Brutten & Shoemaker, 1969) -Behaviors associated with high emotion are likely to be retained permanently (Ayres, 1998) -Therefore, treatment of those with secondary stuttering may be most effective if coping skills are taught (e.g., gentle onsets, slow rate, light contacts) -Emotional conditioning may result in cognitive changes so that cognitive therapy (examining habitual thought patterns) may be a useful adjunct to behavioral therapy

What happens when a person who clutters makes an effort to control their disorder?

-Unlike people who stutter, people who clutter become more fluent, as well as slower and more intelligible when they make an effort to control their disorder -This rarely happens because the person who clutters is not aware that he is cluttering unless someone brings it to his attention.

What should be included in a speech sample for adolescents and adults?

-Use video recording of client talking about a familiar topic such as school of work, 300 syllables or more -Reading sample at appropriate level -Also sample from outside clinic; if none available, record client making a phone call -Analyze with SSI-4 -Analyze Speech rate -Analyze Pattern of stuttering

How do you obtain reliability using the correlation and t-test method?

-Used for multiple samples where you want to compare first and second ratings -Used where point-to-point agreement is not critical, such as overall frequency of stuttering -Calculate correlations between first and second ratings over multiple samples and measure whether there is a significant difference between two samples -Correlation should be above +0.8 and t-test should show no significant difference

What usually occurs in initial contact for preschool children?

-Usually on telephone -Listen carefully and respond to level of concern -Make appointment as appropriate -Provide suggestions to give parents useful ways to start helping child -Case history form sent to family several weeks before evaluation -Informs clinician about family's perception of current stuttering as well as history and development

What does Van Riper's theory hold?

-Van Riper (1982): disruption of timing of muscle sequencing = stuttering

What theories relate to stuttering as a disorder of timing?

-Van Riper (1982): disruption of timing of muscle sequencing = stuttering -Kent (1994): deficit in central timing that regulates speech production and integrates left-brain segmental and right-brain supra-segmental aspects of speech production; this deficit produces stuttering

What does Webster's theory propose?

-Webster (1983): left-hemisphere SMA (supplementary motor area), responsible for initiation, planning, and sequencing of movement, is vulnerable to disruption = stuttering

What are some environmental underlying processes of borderline stuttering at 2 to 3.5 years?

1. Communication stress (a) Models of fast talking/few pauses (b) Interruptions, questions, etc. (c) Models of advanced vocabulary and syntax (d) Competition to be heard 2. Psychosocial stress (a) Conflicts in family (b) Birth of new sibling (b) Changes in home, moving, etc.

What is important to consider regarding the client when assessing?

1. Important to see client with open perspective (a)Don't be blinded by past experiences (b) Don't be limited by expectations created by the case history and referral information 2. Important to understand what clients' goals are 3. Important to accept the client as he or she is

What are some underlying processes of beginning stuttering at ages 3.5 to 6 years?

1. Increases in muscle tension and tempo (a) These increases are seen as a sign that stuttering is worsening (b) These changes may be attempts to control or escape from stutters 2. Effects of learning on stuttering (a) Classical conditioning spreads the emotion associated with stuttering to more situations; this means more tension and faster tempo (b) Instrumental conditioning increases frequency of escape behaviors; this means more eye blinks, head nods, etc.

What are the characteristics of intermediate stuttering at ages 6 to 13 years?

1. Most frequent core behaviors are blocks in which the stutterer shuts off sound or voice. He may also have repetitions and prolongations 2. Stutterer uses escape behaviors to terminate blocks 3. Stutterer appears to anticipate blocks, often using avoidance behaviors prior to feared words. He also anticipates difficult situations and sometimes avoids them 4. Fear before stuttering, embarrassment during stuttering, and shame after stuttering characterize this level, especially fear

What are some characteristics of advanced stuttering at ages 13+ years?

1. Most frequent core behaviors are longer, tense blocks, often with tremors of the lips, tongue, or jaw. Individual will also probably have repetitions and prolongations 2. Stuttering may be suppressed in some individuals through extensive avoidance behaviors

What are the guidelines for obtaining a speech sample and what should be generally observed during the sample for preschool age children?

1. Obtain sample from home and sample from clinic - at least 200 (300 if possible) syllables each 2. General observations: -Frequency of disfluency -Types of disfluency -Nature of repetitions, prolongations, and blocks -Starting and sustaining airflow and phonation -Physical concomitants -Word avoidances

Describe the assessment of feelings and attitudes: perceptions of stuttering inventory.

1. Perceptions of Stuttering Inventory (a) Can be used to help clinician and client assess behavior more objectively, develop treatment goals, and assess progress (b) It assess struggle (S), avoidance (A), or expectancy (E) (c)These categories help the clinician and client understand the motivation underlying each behavior

What assessments would you use with the speech sample of preschool age children?

1. SSI-4: Assess child's severity 2. Speech rate: syllables per minute 3. Feelings and attitudes: -Ask parents -Observe child's reactions to his stuttering -Talk to child directly about his stuttering -Feelings and attitudes can range from being totally unaware to highly frustrated and afraid -May change from time to time

Describe the assessment of feelings and attitudes: the locus of control of behavior scale.

2. Locus of Control of Behavior Scale (a) This scale assesses the degree to which clients believe they control their behaviors (b) How much score changes in a positive direction after treatment has been shown to be predictive of relapse

Characteristics of advanced stuttering continued.

3. Complex patterns of avoidance and escape behaviors characterize the stutterer. These may be very rapid and so well habituated that the stutterer may not be aware of what he does 4. Emotions of fear, embarrassment, and shame are very strong. Stutterer has negative feelings about himself as a person who is helpless and inept when he stutters. This self-concept may be pervasive

Describe the assessment of feelings and attitudes: the overall assessment of speaker's experience of stuttering (OASES).

3. Overall Assessment of Speaker's Experience of Stuttering (OASES): (a) This is a multipart questionnaire that assesses the impact stuttering has on a person's daily life

Beginning stuttering characteristic continued.

4. Escape behaviors are sometimes present in stutterers. These include, among other things, eye blinks, head nods, and "ums" 5. Awareness of difficulty and feelings of frustration are present, but there are no strong negative feelings about self as speaker

What factors predict the persistence of stuttering continued...

5. Duration since onset - longer child stutters beyond 1 year after onset = greater risk 6. Duration of stuttering moments - continued presence of more than one repetition unit, especially more than 3 = greater risk 7. Continued presence of prolongations and blocks - if prolongations and blocks don't decrease as stuttering goes on = greater risk 8. Phonological skills - children whose phonological skills are below the norms = greater risk

How might a "layperson" refer to a normal disfluency?

A layperson might call a normal disfluency a stutter.

What factors predict a natural recovery?

A natural recovery can be predicted by: -female -no family history of persistent stuttering -early onset -good language, articulation and intelligence

What is the difference between fluent and dysfluent?

A person who is dysfluent (has a fluency disorder) might have: -Repetitions -Prolongations -Blocks

Define predisposition.

A susceptibility to developing a condition

Define anticipatory struggle.

A view of stuttering that supposes that stuttering begins when a child experiences problems with communication (e.g. having many repetitions or being told he must try harder to say sounds correctly) and then develops a fear of having difficulty, which then causes tension and fragmentation of speech. This is from the theoretical view of Communicative Failure and Anticipatory Struggle, which was developed by Oliver Bloodstein.

What have adoption studies told us about stuttering?

Adoption studies give us evidence for both genetic and environmental factors.

How do we measure incidence and prevalence?

Although we aim to represent all the people in the U.S., it would be impossible to talk to everyone, so they take a SAMPLE of the population.

What is classical conditioning of stuttering?

An example of classical conditioning with stuttering would be: -Stuttering elicits feelings of dread and tightening of speech muscles -Stuttering (with accompanying dread and muscle tension) occurs repeatedly on the phone (previously neural) -Phone elicits dread and muscle tension

Define Typical Disfluency.

An interruption of speech in a typically developing individual

What should be included in preassessment for adolescents and adults continued.

Attitude questionnaires: (a) Sent to client several weeks before evaluation so they can be analyzed prior to interview (b) Typically used: S-24, SSRSS, Locus of Control, OASES (see Chapter 8 for details) AV Recording: (a) Crucial to have recordings from out of clinic; best if difficult situation, like talking on the phone (b) Analyze prior to evaluation

How would you conduct a direct assessment of speech for a person who may clutter?

Audio or video recorded for 15-20 minutes while performing a number of speaking tasks including: -Narrative about a topic not related to his speech to obtain a natural, unguarded sample -Reading a passage appropriate for his reading level -A conversation in which the client talks about something that really interests him. -For those who clutter who report their clutter is situational, then the clutter needs to be recorded in that setting

What is avoidance conditioning?

Avoidance conditioning is anticipating a stutter and doing something to keep it from happening. "I went to um...um...um...New York." The person speaking avoided stuttering on the feared word, "New York," by saying "um" several times.

What specific information would you provide to parents of beginning stuttering children?

Beginning (usually older preschool children): -Discuss indirect versus direct treatment -Have parents begin to use SR scale and share with you on a weekly basis

Define easy onset.

Beginning phonation by gently bringing the vocal folds together instead of bringing them together quickly and with force.

Describe blocks.

Blocks are typically the last core behavior to appear. The person inappropriately stops the flow of air or voice and, often, the movement of the articulators as well. Most blocks are an inappropriate muscle activity at the laryngeal level. As stuttering persists, the blocks often grow longer and more tense, and you may even see tremors.

What specific recommendations would you provide to parents of borderline stuttering children?

Borderline (usually younger preschool children): -Discuss with parents option of indirect treatment or watchful waiting -Provide video Stuttering and the Preschool Child (SFA #70) -Have parents share weekly results of SR scale

What sounds or words did Brown identify as being more frequently stuttered on by adults who stutter?

Brown showed that adults who stutter do so more frequently on: -Consonants -Sounds in word-initial position -Sounds in contextual speech -Nouns, verbs, adjectives, and adverbs -Longer words -Words at the beginning of sentences -Stressed syllables

What is neurogenic acquired stuttering?

Can be caused or exacerbated by a neurological disease or damage Acquired after childhood Can happen with a stroke, head trauma, tumor or a disease such as Parkinson's Ex: Soilder with head trauma and PTSD, MENSA woman after car accident It may begin after prolonged periods of stress or after some type of traumatic event

What kind of treatment does capacities and demands theory call for?

Capacities and demands theory leads to treatment based on reducing demands and, when possible, increasing capacities

What are two levels of good assessment?

Careful planning, observation, and analysis Trying to understand the whole person or family

What are the characteristics of beginning stuttering at ages 3.5 to 6 years?

Characteristics of beginning stuttering at ages 3.5 to 6 years include: 1. Signs of muscle tension and hurry appear in stuttering. Repetitions are rapid and irregular with abrupt terminations of each element 2. Pitch rise may be present toward the end of a repetition or prolongation 3. Fixed articulatory postures are sometimes evident when the child is momentarily unable to begin a word, apparently as a result of tension in speech musculature

What are the characteristics of borderline stuttering at ages 2 to 3.5 years?

Characteristics of borderline stuttering at ages 2 to 3.5 years include: 1. More than 10 disfluencies per 100 words 2. Often more than two units in repetition 3. More repetitions and prolongations than revisions or incomplete phrases 4. Disfluencies loose and relaxed 5. Rare for child to react to his disfluencies

How might we help children who stutter?

Children who stutter MAY be helped by making communication easier by doing the following: -providing more one-on-one time when the parent can listen -slower speech rate -language complexity not too far above child's level

What should preassessment questions consist of for preschool children?

Clinical questions: Stuttering or normal disfluency? If stuttering, what are the disfluencies like in various situations, and how does it change over time? What are the child's responses? Emotions? What are the family's concerns, expectations, etc.? Treatment options - none, waiting, indirect, direct? Language, articulation, and voice age-appropriate? Any issues for which referral needed?

What should preassessment questions consist of for school-age children?

Clinical questions: What are characteristics of student's stuttering? What are student's feelings and attitudes about speaking? How does it affect him at school and home? Is he eligible for services, according to state regulations?

Clinician-child interaction continued.

Clinician can ask child if he ever gets stuck on words or has trouble talking Children usually relieved by open, reassuring discussion of stuttering If child is reluctant to talk or play with clinician, it's important not to push; clinician can play with an appealing toy and talk to self, and eventually child may join

What factors should be addressed in a closing interview for school-age children in a clinical setting?

Closing interview in clinical setting: -Begin with positive aspects of child and family -Be clear and direct when describing level of stuttering and implications for treatment -Address family's concerns about student's future -Discuss treatment options including family's role

What are some core signs or symptoms of cluttering?

Cluttering appears to be a disorder whose core signs or symptoms are: -Rapid and Irregular Speech Rate that is often Unintelligible and Replete with non-stuttered disfluencies -Language is often disorganized -The person who clutters lacks awareness of his difficulty and the listener's cues signaling they do not understand what the person who clutters is saying -Neuropsychological problems may or may not be present -Neurophysiological basis suggests abnormalities in the basal ganglia

Describe Charles Van Riper.

Coined the term "core behaviors" of stuttering in reference to repetitions, prolongations and blocks Described cluttering as "a torrent of half-articulated words, following each other like peas running out of a spot." Van Riper, 1954 Created theory in 1982 about stuttering: disruption of timing of muscle sequencing = stuttering

Why and when should assessment be after conducted initial assessment?

Continuing assessment: -Periodic assessments can inform clinician and client about progress and final outcome -Assessments should be conducted at regular intervals (e.g., every 10 to 15 weeks); more frequently with preschool children (e.g., every week) -Assess stuttering behavior for all clients; also assess feelings and attitudes, if appropriate, in school-age and older clients

What are the core behaviors of stuttering and who coined the terms to describe them?

Core behaviors of stuttering are: -abnormal breaks in fluency -moments of stuttering -stuttering events -dysfluencies Adopted from term from Van Riper, who used it to talk about basic behaviors stuttering being: -repetitions -prolongations and -blocks He described these behaviors as being involuntary. These core behaviors differ from secondary learned behaviors, which are reactions to these core behaviors

What are the evaluation procedures for cluttering?

Daly's Predictive Cluttering Inventory (2006) is a checklist and evaluates a client in four areas: pragmatics; speech-motor control; language-cognition, and motor coordination writing problems. These ratings help the clinician determine which cluttering characteristics are most salient and are therefore most in need of treatment.

What should be addressed in a diagnosis of adolescents and adults?

Determine if this is "developmental" stuttering rather than normal disfluency, cluttering, neurogenic, or psychogenic stuttering *Intermediate stuttering:* -Younger than age 14 -Blocks, repetitions and prolongations -Escape and avoidance behaviors -Negative attitudes about speaking *Advanced stuttering* -14 years or older -Symptoms as above but more entrenched

What factors should be addressed in the diagnosis of school-age children?

Diagnosis; -Developmental/treatment level -Factors influencing persistence

What does the diagnosogenic theory by Wendell Johnson hold?

Diagnosogenic Theory: -Wendell Johnson (Johnson et al., 1942) proposed that stuttering may result when parents misdiagnose their child's normal disfluencies as stuttering -Johnson thought children who were misdiagnosed by their parents or other listeners developed tension and hesitation in their speech in an effort to avoid disfluencies

What is dysfluency vs. disfluency?

Disfluency = all breaks in fluency, both normal and abnormal Dysfluency = abnormal breaks in fluency SO, normal breaks in fluency are referred to as normal disfluency

What can be categorized as disfluency (with an I)?

Disfluency can mean: normal disfluency OR dysfluency stutter moment of stuttering stuttering event

What is escape behavior and when does it occur?

Escape behaviors occur when the speaker is stuttering and attempts to terminate the stutter and finish the word. Occurs AFTER the moment of begins. -eye blinks -head nods -interjections extra sounds (like uh)

What evidence do we have about deficits in stutterers' performance?

Evidence about deficits in stutterers' performance: -The evidence that many stutterers perform more poorly than nonstutterers in tests of reaction time, speech perception, temporal perception, sequencing, and tracking, as well as on school achievement tests, may reflect inefficient sensory-motor processing -Inefficient sensory-motor processing may be the product of the anomalous neural network organization that is hypothesized to be the basis of primary stuttering -Individuals who stutter may have a range of sensory-motor processing ability, from very great deficits to mild deficits; this may be reflected in the wide range of performances in any large group of stutterers assessed on sensory or motor tasks

What are some risk factors for recovery vs persistence?

Factors that may be associated with persistence of stuttering: -Stuttering does not decrease during 12 months after onset -Stutterer is male -Relatives who have not recovered from stuttering -Below-average nonverbal intelligence scores -Sensitive temperament

What factors may increase normal disfluency at ages 2 to 5 years?

Factors that may increase normal disfluencies: -Demands on language acquisition -Delayed speech motor skills -Stress -Competition and excitement when speaking

Why do certain conditions include fluency?

Fluency inducing conditions have been explained as resulting from reduced demands on speech-motor control and language formation.

What is fluency?

Fluency is timing, rhythm and effort. "The effortless flow of speech." Fluent = little effort when speaking

During trial therapy, what shaping/superfluency techniques can you use to assist with fluency?

Fluency-shaping/superfluency (see Chapter 13 for details) -Teach student to model easy onset, light contact, and flexible rate -Can student follow model? -Does he respond well to coaching to improve his superfluency? -Does he become more fluent?

What should fluency-shaping trial therapy consist of for adolescents and adults?

Fluency-shaping: -Use word list, then phrases -Teach gentle onsets, light contacts, flexible rate -Teach proprioception -In phrases, teach pausing -Teach client to put it all together in a new overall pattern of speaking (sometimes called "controlled fluency" or "prolonged speech") -Can client do this on his own in brief conversational phrases?

What general recommendations would you provide to parents of children with either borderline or beginning stuttering?

For both levels: -Use risk factors and duration of stuttering since onset to determine if treatment should be direct or indirect -Teach parents to use severity rating (SR) scale (see Chapter 8), and have them begin to use it -Answer questions and provide contact information so parents can stay in touch if needed before next appointment

Describe the point by point method of obtaining for intra-rater reliability?

For intrarater reliability: -This is done by marking syllables on an original transcript of a videotaped sample of speech as stuttered or not -Then, the rater re-rates the sample several weeks later. -Reliability = agreements/(agreements + disagreements) X 100 Reliability = agreements divided by (agreements plus disagreements) times 100 (X 100 is to convert decimal to percent) So if there are: 50 agreements and 5 disagreements You would divide 50 by 55: Get: 0.909 and round to 91 %

Define: The Four Phases of Speech Acquisition.

Four Phases of Speech Acquisition - Phase 1: Laying the foundations for speech (birth to 1 year) Phase 2: Transitioning from words to speech (1 to 2 years) Phase 3: The growth of the inventory (2-5 years) Phase 4: Mastery of Speech and Literacy (5+ years)

What information do you need to gather from the parent (case history) for preschool age children?

Gather information about: -Child's birth and development -Family history (stuttering and other disorders) -Onset of stuttering and changes over time -Child's awareness and response to his stuttering -Parents' response to child's stuttering; their ideas about the cause -Previous treatment -Child's personality and environment

What factors predict the persistence of stuttering continued?

Greater risk of persistence is predicted by: 1. Family history - child with family member(s) whose stuttering persisted = greater risk 2. Gender - boys have a greater risk 3. Age of onset - children who begin to stutter later (onset is unusually 2 - 3.5 years), so beginning to stutter after 3.5 years = greater risk 4. Trend of stuttering frequency and severity - if frequency and severity don't decrease within a year after onset = greater risk

Why might audio or video recording be useful with preschool age children?

Helpful to get video of child speaking spontaneously at home 5-10 minutes of parents playing with child is usually adequate, unless stuttering is highly variable, in which case, more than one sample may be needed Provides important sampling of stuttering that may be worse at home than at clinic Parents can leave camera on stand for several days to get child used to it before filming

What is an example of a Phrase repetition

I want a...I want a ice-ceem comb"

What is an example of a Prolongation

I'm Tiiiiiiiiimmy Thompson"

What is escape behavior and how is it related to operant conditioning?

If a behavior reduces negative stimulation, it is "negative reinforcement" or ESCAPE, and it increases the behavior. For example: "I went to N-N-N- the Big Apple." The person speaking escapes from saying the word "New York" by substituting it with "the Big Apple." Head nod is also escape.

What issues might require cultural sensitivity if the client is from another culture?

If the client is from another culture, consider: -Eye contact -Physical touch -Nature of reinforcers -Family interaction patterns -Intentional stuttering -Verbal and nonverbal communication styles -Modes of address Also consider: -Care needed in using an interpreter -Multicultural and multilingual clients require careful analysis of stuttering in all languages

For school-age children, what important information will you gather on a case history form and video?

Important information: -Changes in stuttering since onset -Student's own reaction and family's reaction to stuttering -Past treatment -Impact of stuttering on school performance Video recording may be more stuttering at home or school than in clinic, so this is an important sample

What should initial contact in the clinic setting consist of for school-age children?

In clinic setting, a telephone call to the family can let them know what to expect in the evaluation: -Let them know you'll be sending a case history and perhaps other forms to complete -May be helpful to talk to the student on the phone to describe the procedures and obtain permission for a home video

What should initial contact in the school setting consist of for school-age children?

In school setting, telephone to get permission to evaluate child: -Describe how student was identified and what characteristics of student's stuttering are -Let parent know schools desire to help student become a more effective communicator -Find out if family has noticed stuttering -Maintain a caring, accepting attitude -Explain evaluation process -Ask them to fill out a case history form -Try to obtain a video from home (may be more effective to wait until SLP obtains permission from child)

What does the difference between incidence and prevalence suggest?

Incidence = %5 Prevalence = 1% in school age children and less in adults This suggests that most people who stutter at some time in their lives recover from it.

Which is higher: incidence or prevalence?

Incidence is higher. Remember that: Incidence = percentage of the population that currently stutter (prevalence) + the percentage of the population that has recovered

What is incidence?

Incidence is the percentage of the population who will have the disorder sometime in their life. It is an index of how many people have stuttered at some time in their lives. Like prevalence, incidence figures are not clear cut due to: -different methods for obtaining data -different definitions of stuttering

What other speech and language behaviors should be considered for adolescents and adults?

Informally screen language, articulation, voice If needed, give formal tests Screen hearing Other factors: -Intelligence -Academic adjustment (in adolescents) -Psychological and vocational adjustment

What did Wendell Johnson and other researchers that analyzed his research find?

Johnson interviewed parents and asked them to report the disfluencies they saw. Other researchers interpreted the same data to suggest normally disfluent children and stuttering children had very different disfluencies at onset

What is the theory proposed by Kolk and Postma specifically?

Kolk and Postma have a very specific model (a) Language production is monitored internally (b) If problem in phoneme plan is in error, production halts (c) Repetitions, prolongations, and blacks can all be explained by different responses to an error (d) Analogy can be made of a bicycle production plant (see next slide)

Given what we know about emotions and stuttering, what are the clinical implications?

Many stutterers, especially chronic stutterers, may be helped by treatment that facilitates un-learning of fear-based stuttering behaviors

What was a former definition of cluttering?

Many years ago cluttering was described as "a torrent of half-articulated words, following each other like peas running out of a spot." Van Riper, 1954

What are some concomitant (accompanying) problems of people with cluttering?

May include: -Distractability -Hyperactivity -Learning Difficulties -Articulation Problems -Auditory Processing Problems -Cluttering is sometimes accompanied by stuttering

What are some methods of assessing school-age children?

Methods of assessing: -Informally by observation and discussion with student -Informally with materials (e.g. "worry ladder" from workbook by Chmela & Reardon, 2001) -Use formal assessment with discussion: CAT or A-19

What are the underlying processes of advanced stuttering at 13+ years?

Minimal influence of original constitutional, developmental, and environmental factors Learning and experience, however, have changed brain structure and function Avoidance learning has created enduring stuttering patterns Cognitive learning creates negative self-concept (This comes from listener reactions from childhood and later) Stutterers also project their own negative feelings about stuttering onto others

What does Neilson and Neilson's theory, relating to stuttering as a reduced capacity for internal modeling, hold?

Neilson & Neilson (1987): -Children learn to talk by hearing the sounds of their language and developing a "model" of how to move their articulators to make the sounds they desire -They use auditory feedback as they babble and talk to update their internal model as their speech mechanism changes size as they grow -Stuttering is thought to result from a weakness in using the internal model to transform the child's plans for the sounds of a word into motor commands leading to movements producing speech (see next slide)

What is the high end estimate of incidence?

On the high end, incidence is estimated at 5%.

What should occur in the initial child-clinician interaction with preschool age children?

Opportunity to observe child's stuttering and his response to various stimuli If child is quite fluent, clinician may speak rapidly and ask many questions to see if stuttering appears If child is stuttering, clinician may experiment with fluency facilitating interaction, such as speaking slowly If child is aware, discuss with parents the benefit of talking to child about stuttering

What should be included in the parent interview for preschool age children?

Parent interview: -Interview with child present or not - -Let parents know the overall flow of the evaluation -Begin with open-ended questions about what parents' concerns are -Careful, nonjudgmental listening is important -Leave time at end for parents' questions

Why should a parent-child interaction be observed prior to the clinician's assessment of preschool age children?

Parent-child interaction: -Done first to get unbiased sample -Opportunity to observe child's stuttering and awareness of it -Opportunity to observe parent's style of interacting with child -Video record for later analysis

What are some types of normal disfluency?

Part-word repetition Single-syllable word repetition Multisyllabic word repetition Phrase repetition Interjection Revision-incomplete phrase Prolongation Tense pause

What is a physiological tremor?

Physiological tremor: A factor that may make the initial disorder more severe

What are three methods of determining reliability?

Point by point method Percent error method Correlation and t-test method

What should be gathered and analyzed from the speech sample for school-age children?

Preliminaries: (a) Ask student's permission to video record (b) Record 300-400 syllables of student's conversation (10 minutes) (c) Obtain 200-syllable reading sample -Pattern of disfluencies: Observe degree of tension, struggle, escape, avoidance, and estimate developmental/treatment level -SSI-4 -Speech rate: compare with normal for age

When does prevalence decline?

Prevalence declines after puberty.

What is prevalence?

Prevalence is the percentage of the population that currently has the disorder. It tells us how many people currently stutter. It is a term used to indicate how widespread a disorder is.

Define articulation.

Production based (or motor based) speech sound disorders

Describe prolongations.

Prolongations usually appear somewhat later than the repetitions. Sound or airflow continues, but the movement of the articulators has stopped. Can be as short as 1/2 a second, but in rare cases, they're longer than that.

Describe repetitions.

Repetitions are observed in young children who are just beginning to stutter. Usually a sound, syllable or single syllable word that is repeated several times like the person is stuck.

What are the core behaviors of stuttering?

Repetitions, prolongations and blocks. These terms were adopted from Van Riper.

What are some sensory processing deficits in stutterers?

Sensory processing deficits in stutterers include: -poorer central auditory processing, especially for temporal information -auditory evoked potentials have longer latencies and lower amplitudes, especially for linguistically complex stimuli -less right ear (left-brain) advantage in processing linguistically complex sounds -stutterers may be poorer at processing tactile and visual information -masking and other changes in auditory feedback decrease stuttering

What are some sensory-motor control deficits in stuttering?

Sensory-motor control deficits include: -slower reaction times -slower speech during fluency -slower on non-speech sequencing -slower at tapping at a comfortable rate, but faster and more variable at a fast rate -not as able to focus on left-hemisphere motor control -poorer at auditory motor tracking

What are some constitutional underlying processes of borderline stuttering at 2 to 3.5 years?

Speech and language development: -Some language and speech skills may be more advanced than others -Inefficiencies in some language production processes

What do we know about spontaneous or natural recovery?

Spontaneous recovery is recovery without treatment. Children started to stutter between 3 and 5 years of age. 71% recovered within two years By 8 or 9 years old, 85% had recovered.

What theories relate to stuttering as a disorder of brain organization?

Stuttering as a disorder of brain organization theories: -Orton & Travis (1931): lack of hemispheric dominance leads to mistiming of muscle activation = stuttering -Geschwind & Galaburda (1985): left-hemisphere delay, right-hemisphere dominance --> inefficient for speech = stuttering -Webster (1983): left-hemisphere SMA (supplementary motor area), responsible for initiation, planning, and sequencing of movement, is vulnerable to disruption = stuttering

What is the difference between normal and abnormal breaks in fluency?

Stuttering is abnormal breaks in fluency. Breaks in fluency can be normal. It is sometimes difficult to differentiate the normal from abnormal breaks in fluency. disfluency = umbrella term for all breaks in fluency

What is stuttering?

Stuttering is defined as part-word repetitions, and single-syllable word repetitions, prolongations, and blocks.

What conditions have been known to induce fluency by reducing or eliminating a stutter?

Stuttering is reduced/eliminated when speaking: -Alone or relaxed -In unison with another speaker -To an animal or infant -In time or rhythmic stimulus or singing -In a different dialect -While simultaneously writing -While swearing -In a slow, prolonged manner -Under loud masking noise or while listening to delayed auditory feedback -When shadowing another speaker -When reinforced for fluent speech

Describe the overarching components of stuttering.

Stuttering is: -a disorder of neuromotor control of speech -influenced by language production -perpetuated by temperament and complex learning, and the response of their environment to their speech

What should stuttering modification trial therapy consist of for adolescents and adults?

Stuttering modification: -Have client freeze a moment of stuttering, maintaining posture and tension; this may require some coaching, especially on stop sounds -Have client become aware and describe what he's doing to hold back speech as he stutters -Have client stay in posture but reduce tension and slowly produce first sounds of word and then rest of word normally -See if client can do this on his or her own after some clinician-guided practice

What factors predict the persistence of stuttering?

Stuttering persistence can be predicted by: 1. family history 2. gender 3. age of onset 4. trend of stuttering frequency and severity 5. duration since onset 6. duration of stuttering moments 7. continued presence of prolongations and blocks 8. phonological skills

What is developmental stuttering?

Symptoms develop gradually as a child develops their speech, usually during an intense time of language acquisition There are more boys than girls that stutter (3:1 ratio with young children) Begins during childhood without an apparent link to psychological issue or trauma Usually reported parents. First sign is usually repetitions of syllables and words - and possibly prolongations and blocks. Some stuttering can occur in the natural process of learning language

What factors potentially cause or contribute to stuttering?

The factors that contribute to stuttering include: -Hereditary factors -Congenital and early childhood traumas -The structure and function of the brain -Sensory and sensory motor factors -Emotional factors

When assessing stuttering behavior, what behavior should be counted as stuttering?

The following behaviors should be counted as stutters: -Part-word repetitions -Monosyllabic whole-word repetitions -Sound prolongations -Blockages of sound or airflow -Unequivocal sound or word avoidances

What is the prevalence of adults who stutter?

The prevalence of adults who stutter = less than 1%

What is the prevalence of children who stutter throughout the school years?

The prevalence of children who stutter throughout the school years = 1%

What is the prevalence of kindergartners who stutter?

The prevalence of kindergartners who stutter: = 2.4 %

What is the issue or problem with the estimate of spontaneous recovery?

The problem with the estimate of spontaneous recovery is: -Only the high-end estimate of 80% is widely quoted -This accuracy of this high estimate may be inflated -There may have been FALSE cases of spontanous recovery due to: Not all those people actually stuttered to begin with. If they did, they didn't actually recover. If they did recover, not all were truly spontaneous.

How rigid are these four levels of developmental stuttering?

There are many exceptions to these levels of development Four levels of stuttering development useful to determine treatment approach

What is the recovery rate for people who stutter?

There is an 80% recovery rate for those who stutter. 4 out of 5 people who stuttered will recover

What are secondary behaviors of stuttering?

These are learned reactions to the basic core behaviors. Ex: blinking, avoiding certain words, escape behavior

Define Borderline Stuttering.

This is the earliest or lowest level of stuttering, usually seen in children ages 2 to 3.5. This type of stuttering is characterized by more frequent part-word and single-syllable whole-word repetitions than typically developing children have, but without awareness or concern on the part of the child.

Define Beginning Stuttering.

This level of stuttering is usually seen in children between ages 3.5 and 6, although it may occur before and after those ages. It is characterized by more tension and hurry in disfluencies than that seen in borderline stuttering. Stuttering usually consists of repetitions and prolongations, but some children will also exhibit blocks. Escape behaviors appear in this level of stuttering.

Define avoidance conditioning.

This type of leaning occurs when a person uses a behavior to try to prevent an unpleasant occurrence by doing something; it is perpetuated by the successful prevention of the unpleasant experience, at least some of the time. In stuttering, avoidance conditioning may begin when a person first escapes from a stutter by saying an extra sound or word (like "uh"). Then he may make that sound even before saying the fearing word, like "uh, can I have some pizza?"

Those who have recovered from stuttering fall into which two categories?

Those who recovered be categorized as: population who have recovered due to treatment AND population who have recovered spontaneously Also, remember that incidence is made up of those who stutter currently and all of those who have recovered, either spontaneously or through treatment.

What are avoidance behavior?

To avoid the stuttering, they might change the word they were planning to say. Occurs BEFORE the moment of stuttering begins. They can consist of: postponement starters substitutions hand movements They can become strong habits because they allow the person who stutters avoid the stutter.

How do you deal with avoidance conditioning?

To deal with avoidance conditioning, you need to: -Decrease fear of stuttering --> if the client avoids by using "um" as in "My name is um...um...um...Barry," have the client practice staying in stuttering on "Barry" (reward this) and also learn to reduce tension and release word easily -Reward non-avoidance --> have client practice saying "My name is Barry," without the "um" but with an easier stutter on "Barry" (reward this empathetically)

How do you deal with classical conditioning?

To deal with classical conditioning, you need to: -*Decondition* (associate behavior with NEUTRAL stimulus) --> have the client keep stuttering until the fear is gone, so there is no negative stimulus -*Countercondition* (associate behavior with POSITIVE stimulus) --> have client stutter and receive praise for keeping it going, so there is a positive stimulus

How do you deal with operant conditioning?

To deal with operant conditioning, you need to: -Stop reward for unwanted behavior --> have the client not release the word immediately after tense squeeze, head nod, eye blink, or other escape behavior (deny the reward) -Start reward for wanted behavior --> have the client stutter to easy prolongation before release (reward given)

How do we take samples for incidence?

To get a sample for incidence: -random samples -need adequate sample size -self-report only -incidence = about 2% to 5%

How do we take samples for prevalence?

To get a sample for prevalence: -random samples -need adequate sample size -can be self-report or diagnosis by SLP -most studies conducted in US or Europe -prevalence = about 1%

What have twin studies told us about stuttering?

Twin studies have shown: -There is a greater concordance among identical twins (meaning both twins are more likely to stutter) -Whether stuttering occurs is 2/3 (two-thirds) genetics and 1/3 (one-third) environment.

What is the two-stage model of stuttering?

Two-stage model of stuttering: -Stuttering may often develop in two stages -Primary stage is simpler disfluencies that are the result of how the brain handles speech and language production -Secondary stage is a more complex pattern that is the result of the child's and environment's reaction to disfluencies

What are the different types of stuttering?

Types of stuttering include: -Developmental stuttering -Neurogenic acquired stuttering -Psychogenic acquired stuttering

Why does prevalence decline after puberty?

Unless treatment alone is responsible for such remissions, some aspect of growth or maturation allows many individuals to recover from stuttering. If they simply recover, this is called spontaneous recovery. It could be due to: -relaxing more -child was just struggling with new vocabulary -etc.

Evaluation procedures for cluttering continued.

Useful to calculate the ratio of the number of syllables spoken that are part of the intended message and analyze which are stuttered and which are cluttered. It is suggested that when stuttering is mixed with cluttering, a client's cluttering may not be noticed until his stuttering is substantially reduced by therapy.

Why is there so much variation between studies?

Variation may be due to: -accuracy of data due to self-report (someone might now report their stuttering or not stuttering correctly) -problem accurately measuring percentage of people who have recovered

What is cluttering?

Very rapid speech rate & very little timing between words Difficult to understand Can use a metronome to work with students with this cluttering behavior

What terminology should we use when referring to a person with dysfluency?

We always want to use person first language, SO USE: person who stutters NOT: stutterer

Define phonology.

When referring to SSD: speech sound errors that are rule based (or linguistically based)

What is the theory proposed by Wingate (1988); Perkins, Kent, and Curlee (1991); and Kolk and Postma (1997)?

Wingate (1988); Perkins, Kent, and Curlee (1991); and Kolk and Postma (1997) have suggested stuttering results from deficits in planning and assembling the units for language production

What theories related to stuttering as a language production deficit?

Wingate (1988); Perkins, Kent, and Curlee (1991); and Kolk and Postma (1997) have suggested stuttering results from deficits in planning and assembling the units for language production Kolk and Postma have a very specific model (a) Language production is monitored internally (b) If problem in phoneme plan is in error, production halts (c) Repetitions, prolongations, and blacks can all be explained by different responses to an error (d) Analogy can be made of a bicycle production plant (see next slide)

What is the general process of evaluating a person who may have a clutter?

With school aged children using a multidisciplinary approach usually works the best: -SLP -Classroom Teacher -Special Educator -Psychologist -Audiologist

What strategy would you use to assess possible therapy techniques with school-age children?

You would use *trial therapy* Stuttering modification: -Have student catch clinician's pretend stutters -Have student put in pretend (or real) stutters, and have clinician catch student and reward him -Have student control length of clinician's pretend stutter -Roles reverse, and clinician signals student to make stutter longer -Can student hold onto stutter, reduce tension, and release stutter slowly?

Define didochokinesis.

a test involving the rapid repetition of syllables, typically part of a speech mechanism exam, which is intended to evaluate oral motor skills independent of phonological skills

Describe Oliver Bloodstein.

proposed that in many cases, stuttering begins when a child finds talking difficult (Theory of Communicative Failure and Anticipatory Struggle); anticipated difficulty in talking produces tension and fragmentation of speech; this leads to more frustration and failure in communication, which increases anticipation of difficulty (it cycles)

Define phonological processes/patterns.

simplification of a sound class in which target sounds are systematically deleted and/or substituted

Define stimulabilty.

the ability to correctly produce a speech sound (that is not currently being produced correctly) following presentation of a correctly produced model

Define intelligibility.

the percentage of words understood by the listener; capable of being understood or comprehended

Define contextual testing.

the practice of testing a sound in a variety of phonetic contexts, being that sounds may be easier to produce in some contexts as opposed to others

Define morphology.

the study of the forms of words

Define comorbidity.

when two (or more) disorders exist within the same individual