Fluency Disorders

Disfluency and Dysfluency

"Disfluency" = indicates the fluency breaks of "normal" speakers "dysfluency" = describes the abnormal fluency breaks of people who stutter

Disfluency index

1. Count the total # of syllables or words in the speech sample (e.G., 500 word sample) do not count stutters as part of your syllables! 2. Count total number of disfluencies (e.G., 75 repetitions, 50 pauses, 25 sound prolongations = 150 total disfluencies) 3. Divide total disfluencies by total syllables/words (e.G., 150 divided by 500= .30 4. Change to a percentage for total disfluency index (e.G., .30 x 100 = 30% disfluent speech present in the speech sample Example: 300 syllables and 16 stutters observed = .053333 x100 = 5.333 or 5.3%

What does real time analysis address? (2 most fundamental measures)

1. Frequency of disfluency How often 2. Types of disfluency What is it

Characteristics of borderline stuttering in a younger preschool child (guitar, 2014)

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

Older teens and adults: advanced stuttering, ages 13+ Characteristics of advanced stuttering in older teens and adults (guitar, 2014)

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 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

Characteristics of normal disfluency in the average nonstuttering child (guitar, 2014)

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

Characteristics of normal disfluency in the average nonstuttering child (guitar, 2014)x

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

Characteristics of Cluttering

A fluency disorder characterized by a rate that is perceived to be abnormally rapid, irregular, or both for the speaker. These rate abnormalities further manifest in one of more of the following symptoms: 1.An excessive number of disfluencies, the majority of which are not typical of people who stutter 2.The frequent placement of pauses and use of prosodic patterns that do not conform to syntactic ad semantic constraints 3.Inappropriate (usually excessive) degrees of coarticulation among sounds, especially in multisyllabic words Cluttering can be identified by 7 ounds cluttered and chaotic An already rapid rate of speaking often accelerates as the speaker produces longer sentences (Daly, 1986) Words are often poorly articulated and produced at a rate that may be unintelligible. In speaking and writing, the person seems to lack the ability to attend to the details of the task. Oral reading sounds as though the person is demonstrating speech-reading aloud and is attempting to produce the entire page of text in a single utterance Speaker may have difficulty describing the details of an activity or event. Think ADHD

The International Classification of Functioning, disability and health (icf) for stuttering A person who stutters has an: impairment in Thus, they may also have an: impairment in

A person who stutters has an: Impairment in body function: a problem lies within the production of flueny speech (possible neurologial differences) Thus, they may also have an: Impairment in body structure, which may ultimately be associated with the underlying neurological cause of the disorder

Tips for counting stutters (gregory, et. Al., 1996)

A repetition of a sound, syllable, or word is one disfluency regardless of the number of iterations (I.E., um um um um I wa- wa-wa-want the red one = 2 stutters and 5 syllables). A prolongation of a sound is one disfluency. A block on a word is one disfluency regardless of the duration. An unnaturally long pause is one disfluency if the pause is longer than comfortable for the listener. This is a judgment/the pause should call attention to itself. A revision is one disfluency. In reading, the omission, modification, or addition of a word or words is one disfluency. Filler and starters are counted as disfluencies; several filler words (um, uh, etc.) prior to saying the next word, are counted as one disfluency.

Assessment for Feelings and attitudes for School Age Children

A-19 scale (guitar & grims, 1977) Communication attitude test (cat) (brutten & dunham, 1989); teachers assessment of student communicative competence (tascc) (smith, mccauley, & guitar, 2000)

These contextual factors can lead to

Activity limitations: Difficulty communicating with other (using the telephone, talking to friends, socializing) Difficulty preforming school or work related tasks (giving presentations, asking and answering questions) Participation restrictions: Difficulty achieving educational, social, vocational objectives (succeeding in school or work) *note that these are the aspects that idea says we are supposed to address and, increasingly, third party payers emphasize functional changes in determining treatment success.

Current perspective

Although the diagnosogenic theory is no longer believed by most researchers, it still shares an important feature with many other theories that have been proposed over the years. Specifically, it attempts to describe the root cause of stuttering in terms of a single, specific factor (the parental misdiagnosis of stuttering)...a unidimensional theory fails to explain the complexity of a multi-dimensional disorder such as stuttering (conture, 2001).

Stuttering as a multifactorial, dynamic disorder

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 They see stuttering as "dynamic" (changeable) 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. A neurodevelopmental, epigenetic, multifactor disorder Conture (1990) the history of stuttering reflects a multidimensional problem that has repeatedly and successfully defied unidimensional solutions.

Cluttering info

Appears to be related to difficulty formulating and organizing language. Disorganized flow of information, false starts, interjections, and phrase repetitions Involves aspects of learning, verbal and written expression, and perception Rapid rate of speech; abnormal phrasing patterns Frequent maze behaviors (information content is reduced) No increased physical tension Speaker has a lack of awareness of awareness concerning his or her ineffective communication Frequent repetition of 1-syllable words and first sound/syllable of multisyllabic word

Consider....... for risk factors

Are they going to have negative reactions? Do they already? Is stuttering going to impact how they participate in activities, what they do in different social situations, how they interact with their friends, how likely they are to participate at school in academic environments?

Theories concerning constitutional factors

As a result of physiological tremor in speech musculature which targets neuromusculature malfunctions that may explain the tension and tremors of secondary stuttering

Theories concerning constitutional factors Include views on stuttering :

As an anomaly of how the brain is organized for speech and language As a disorder of timing of the sequential movements for speech As a result of deficits in the internal modeling process used to control speech production As a disorder of spoken language production The focus of these 4 views is of cortical and subcortical mechanisms that control the planning and production of speech and language to produce the initial repetitions and prolongations of early stuttering.

Other Behaviors

Associated physical tension or struggle Secondary behaviors (e.g., eye blinks, facial grimacing, changes in pitch or loudness)

Negative reaction or frustration

Avoidance behaviors (e.g., reduced verbal output or word/situational avoidances) Family history of stuttering

Disfluent speech can .......

Be a sign of cluttering Be a sign of a language problem Be a sign of another type of speech problem that is not stuttering Be an indication that a child has tried to repair a mistake in planning or producing his message Be a sign of stuttering

How is neurogenic stuttering treated?

Because many conditions can cause neurogenic stuttering and affect the frequency with which it co-exists with other communication impairments, there is no single treatment approach that is effective in alleviating its symptoms. Treatment is often carried out by a speech-language pathologist working in conjunction with the clients' physicians.

Psychogenic

Begins suddenly after emotional trauma or tress; also occurs in patients with a history of psychiatric illness

Types of dysfluencies that are stutter like

Blocks, Prolongations Clusters/Multicomponent

Distinguishing Cluttering from Stuttering

Can coexist Approximately 5-7% of individuals produce purely cluttered speech (Manning & DiLollo, 2018) Majority of clutterers also stutter, distinguishing patterns of fluency problems is useful Individuals who stutter typically have more fluency breaks when asked to monitor their own speech, people who clutter often show an immediate improvement in rate, intelligibility, and naturalness. However their ability to monitor is short-lived Clutterers have difficulty selecting the word he or she wants to use whereas a PWS usually knows the word he or she wants to say but may avoid, substitute, or use circumlocution to conceal the stuttering. "Stutterers know what they want to say but are interfered in their attempt to produce various words, whereas clutterers do not necessarily know all of what they want to say—or how—but say it anyway" (St. Louis et al. , 2007)

Measurement procedures

Can collect in real time or based on a transcript Real time analysis: collect and analyze data at the same time, while the client is speaking or "offline" from a videotape. It is fast and efficient, but limited in the amount of data that can be collected at one time. Flexible by allowing the clinician to select syllable or word measurement; the behaviors measured (types of disfluency vs stuttering) and sample size. Other behaviors measured such as duration and # of iterations can also be measured.

Normal disfluencies: ages 2-5

Categories of normal disfluencies (guitar, 2014) Type of normal disfluency Example Part-word repetition "mi-milk" Single-syllable word repetition "I...I want that" Multisyllabic word repetition "lassie...lassie is a good dog" Phrase repetition I want a...I want a ice-ceem comb" Interjection "he went to the...uh...circus" Revision-incomplete phrase "I lost my...where's mommy going?"

Older preschool children: beginning stuttering, ages 3.5-6

Characteristics of beginning stuttering in an older preschool child (guitar, 2014) 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 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

School-age children: intermediate stuttering, ages 6-13

Characteristics of intermediate stuttering in a school-age child (guitar, 2014) 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

Factors to consider with older speakers The variability of stuttering

Child not so much bc thats more parental fear Why is the person seeking assistance now? You have an adult who walks in but they're child onset. Its about getting it out fluently What is the person's level of motivation If that older speaker doesnt wanna put the work in its not gunna be successful The frequency of stuttering is one (relatively minor) indicator of severity. What does the person do when they stutter? Look at secondary behaviors tension- negative reactions TYPE of disfluency What does the person do because they stutter? What we need to figure out Is it variable Self medication- drugs,alcohol, cutting The possibility of self-medication. (bolton et al., 2001; iverach et al. 2010)

Types of Fluency Disorders

Childhood onset Stuttering started when they were a child Cluttering Neurogenic Psychogenic Important

Reading and stuttering

Children who stutter typically know how to read the printed form of the word; they just cannot speak the printed form fluently. In contrast, children with reading disorders are likely to have difficulty with decoding the printed form (kuhn & stahl, 2003).

Underlying processes: environmental for younger preschool children borderline stuttering, ages 2.0-3.5

Communication stress Models of fast talking/few pauses Interruptions, questions, etc. Models of advanced vocabulary and syntax Competition to be heard

Psychosocial stress

Conflicts in family Birth of new sibling Changes in home, moving, etc.

Stuttering can affect

Continuity Rate Rhythm Effort

How does stuttering affect Continuity and Rate

Continuity - the smoothness of speech, how much speech is affected by disfluency. Example: Continuity is decreased by how often and where pauses happen in speech and by how many extra sounds are added such as "um", "well", "uh", repeating or re-wording. Rate - how fast or slow speech is, it is measured by words/syllables spoken per minute and relates to information flow as well as sound flow. Example: The rate of information and sound flow is too slow for people who stutter and too fast for people who clutter. That's why it can be harder to listen to them. In an eval count the words not syllables

What are these studies based on for natural recovery?

Data is from population study verses what we see in a clinical population Doesnt take us into accountW

Criteria for diagnosing stuttering

Debate as to stuttering disorder verse typical nonfluent speech Typical disfluency period may occur between 2-5 years of age Diagnosis can be made if one or more conditions occur: 1. 10% or greater total disfluency index 2. 3% or more disfluency indexes for repetitions, prolongations, and blocks (slds) 3. Most prevalent disfluency types are of blocks, part-word repetitions (syllable or sound repetitions), monosyllabic whole word repetitions, sound prolongations, displaying physical tension or struggle, and/or negative reaction 4. 1 second or longer duration of disfluencies 5. Secondary behaviors are present 6. Parent of clients of client reveals significant concern

Types of stuttering

Developmental Neurogenic Psychogenic

Considerations

Developmental or Acquired Childhood onset or adult onset Developmental Idiopathic It can have an organic nature Persistent Developmental Acquired : neurologic or psychogenic

Pharmacogenic stuttering

Diagnosis (in collaboration with physician) Reconstruction of drug history (past and recent) Change medication Temporarily withhold the drug Find out the half life and then you can see that if when its removed from the bloodstream if the stutter goes away Replace by other drug Vary the dosages Drugs elicit mainly primary stutter symptoms (repetitions, prolongations, blocks) with repetitions being the most frequent symptom

Theoretical Perspectives Developmental and environmental factors:

Diagnosogenic theory Communication failure and anticipatory struggle Capacities and demands

Theories concerning developmental and environmental factors

Diagnosogenic theory, which implicates the listener's response to the disfluencies of the child Anticipatory struggle theory, which suggests that a child may develop stuttering as a result of negative anticipation of speaking after he has had frustrating or embarrassing experiences in communicating Capacities and demand theory, which postulates that stuttering arises when the child's capacities for rapid, fluent utterances are unequal to the demands within the child himself or within the environment

Cluttering: how do you Diagnosis and Evaluate

Direct assessment of speech Videotape during a variety of speaking tasks Assess rate, especially during bursts of fast rate Separate counts of normal and stutter-like disfluency Ratio of syllables spoken in intended message to syllables spoken overall Percent intelligibility to unfamiliar listener Language assessment Assessment of cluttering characteristics (see Daly & Burnett-Stolnack, 1995) Assessment of coexisting disorders

Within-word disfluencies:

Disfluencies that occur within a word boundary such as repetitions of parts of words, prolongations, or blocks. Stuttered speech is said to contain higher proportion of within-word disfluencies (as opposed to disfluencies that happen between words or across words, such as hesitations, fillers, and repetitions of whole words). Note that disfluencies of typically developing children may also include within-word disfluencies

Disrhymic phonations, Anti expectancy Circumlocution definition

Disrhythmic phonations: A sound prolongation, broken word, or other instance of ongoing phonation being stopped, extended or distorted Antiexpectancy devices: an unusual way of speaking or acting that seems to reduce stuttering, like laughing and pretending that most things said were a joke or speaking with an accent that the speaker pretends to have Circumlocution: Rather than stutter on a word, a person who stutters might use a different way of saying something

Real time analysis

Does not require transcription. However, you need a coding system for fluent words disfluent words. Pace could be your enemy here Do not worry about missing words or maintaining pace with the speaker Focus on obtaining a representative sample

Assessing duration

Duration: how long each disfluency lasts. Time blocka, prolongations, pauses, repetitions (not phrase rep) to determine a duration In general, the longer disfluencies reflect greater severity A measure of duration can be documented either in terms of the number of iterations included in a repetition or the number of seconds that a prolongation or block lasts Common practice is to average duration of three longest stutters (identify the type and provide examples in your report)

Effect of Down's Syndrome and ASD on Fluency:

Effect of Down's Syndrome on Fluency: Repeating whole words while trying to think of the next part of the utterance; long pauses in the middle of sentences when unable to think of what to say next; pauses in unusual places in sentences (stop-start speech patterns) . Fluent speech is dependent of a steady flow of air Effect of Autism Spectrum Disorder on Fluency: Perseverations, language organization, cluttering (disinhibition, working memory), final sound and syllable repetitions ("light-t-t), between syllable insertions ("way-hay") , within word breaks ("op---en), and final sound prolongations ("thisssss") predominate in their speech

Clinician's attributes

Empathy: the ability to understand the client's feelings, thoughts, and behaviors; learn to listen deeply and acceptingly Warmth: caring and unconditional acceptance that stimulates client's learning and unlearning Genuineness: honest and self-acceptance; being able to be blunt with client when needed Preference for evidence-based practice: valid and reliable measures; evidence for effectiveness of treatment Commitment to continuing education Critical thinking and creativity: will this approach work for my clients in my environment? What does this client need from me, and how can I arrange it?

Assessing secondary 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

Assessing types of disfluencies

Examine not only the number of disfluencies but also the specific types of disfluencies All people produce all types of disfluencies, observe the nature and types of disfluencies that are exhibited. Are the typical or stuttering-like? Always observe for the presence of tension or struggle—regardless of the type of disfluency being produced, this is a strong indicator that the client may feel a loss of control

Facial, Vocal, Syntactic and Semantic Secondary characteristics

Facial: This involves facial expressions like grimaces, loss of eye contact, closing/blinking eyes. Vocal: This is one of the most noticeable behaviors associated to stuttering. It involves talking faster or louder, change in voice quality, Pitch goes up and down and other vocal related behavior that are associated with stuttering. There is also the fear of sounds voices and words as well as repetitions and prolongation of words. Syntactic and Semantic: Gestures, word/sound changes, use more injections like hmm, ehhh, etc. These behaviors are very obvious in people who stutter and it could be very embarrassing to people who stutter and can make them lost confidence in talking freely in the public.

Feelings and attitudes and empathy definitions

Feelings and attitudes: Feelings are emotions experienced by the person who stutters, especially regarding the experience of stuttering and perceived listener responses. They can vary from one time to the next. Attitudes are more long-lasting; they reflect the stutterer's beliefs about how people perceive them and how they perceive themselves in regard to their stuttering. Empathy: The capacity to understand another's perspective, beliefs, and emotions. Having this capacity to some degree allows clinicians to undertake appropriate treatment and to develop trust in the working relationship.

Green Flags- Good things

Female Less than three years old No relatives who stuttered; relatives who did, recovered Decreasing pattern of slds within 1 year of onset Decreasing severity ratings by clinicians and parents Child stuttering is within 1 year of onset Decreasing secondary behaviors Few repetitions Slower rate of repetitions Few reactions to the stuttering by the child No concomitant learning problems Onset of stuttering at ages 2-3 No delays in phonological development

Cluttering: Diagnosis and Evaluation

For school students, a multidisciplinary approach is useful: SLP, teacher, special educator, psychologist, audiologist Case history and interview: Parents' and teachers' perceptions of problem How long cluttering as existed When and where it appears Background on student and family Reasons for seeking treatment now Look at these communicative dimensions: Cognition, Language, Pragmatics, Speech, Motor

World health organization(who) for stuttering and functions

For stuttering, structures that are dysfunctional are cortical and subcortical structures, such as white matter tracts that may be critical for coordinating, planning, and execution, and sensory feedback for speech Functions that differ in stuttering are the interruptions of speech flow that characterize the disorder Their brain is effected

How do we count stuttering behaviors?

Frequency of disfluency Types of disfluencies Duration of disfluencies Severity of disfluencies

Assessing frequency

Frequency: how often do disfluencies occur (oral reading and/or in speech) Most commonly reported as percentage of syllables stuttered (sample size should be 200-300 syllables), although some use percentage of words stuttered or number of stutters per 100 words. When assessing a client that can read, it can be helpful to compare the frequency of stuttering in reading to that in speaking. If stuttering is markedly greater in the reading task, this may be because the speaker is avoiding words he/she expects to stutter on in the speaking task, but the cannot do this when reading. Free online counter http://www.Natkeverlag.De/silbenzaehler/index-en.Html

Assessing severity

Given the variability of stuttering, this is challenging Severity reflects an overall impression that listeners may have when they listen to an individual who stutters Can range mild to severe in different speaking situations Standardized tests or assessment protocols document the severity of stuttering by comparing the client's stuttering to that or age matched peers Assessment of severity is a clinically relevant measure because it captures what the listeners experience. However, stuttering is not a very "clear" disorder so it cannot be only data driven. For example, if a person exhibits a disfluency rate of 5% and that negatively impacts their life, that tells me much more about severity than the ssi-4 would. Initial severity does not predict chronicity! Severity doesn't equate to an adverse impact!

Cluttering: Treatment

Good candidates: ability to control cluttering on demand; motivation to improve Increase client's awareness of speaking rate Increase self monitoring skills This is the biggest hoop Improve linguistic and narrative skills Facilitate fluency (rate alternating techniques and fluency shaping targets of respiration, phonation, and articulation) Increase client's knowledge and awareness of cluttering Over-articulation Increase pausing and phrasing/use of pacing techniques

Neurogenic Stuttering Symptoms

High frequency words stuttered Few, if any, secondary behaviors Disfluencies on initial, medial, and final sounds Disfluencies on content and function words Speaker is usually not anxious about his/her speech No adaptation effect

Diagnostic Considerations How do you diagnose a disorder which is constantly changing and varies greatly for each individual?

How do you diagnose a disorder which is constantly changing and varies greatly for each individual? Collect all the data! Just as we plan to treat the entire disorder, we must also assess the entire disorder! Clients arent number- although numbers may help qualify, your client is more than a number You might have to tell them that their number may not qualify them and you have to advocate because they are more than a number

Psychogenic Acquired Stuttering:

ICD-10: F98.5 Signs of psychogenic etiology: Adult onset during stress Absence of neurological factors Dramatic improvement with trial therapy Increased severity under fluency inducing conditions Unusual secondary struggle behaviors

Neurogenic Stuttering information

If other communication disorders are also present, additional therapy directed at alleviating their effects may enhance fluency as well. Physicians, nurses, occupational, physical, and respiratory therapists may also be able to provide assistance in dealing with medical conditions and symptoms which have an impact on speech fluency. The disorder whose symptoms most resemble those of neurogenic stuttering is developmental stuttering. Developmental stuttering may persist into adulthood. In some cases, its symptoms may be noticeably worsened following injury, disease, or trauma, possibly making diagnosis between the two disorders more difficult. Similarly, an individual who had recovered from developmental stuttering in childhood may experience a re-emergence of stuttering following neurological injury or disease. In the vast majority of cases, however, the sudden appearance of disfluent speech in an adult should be considered abnormal. Developmental stuttering should only be considered as a possible cause when there is a prior history of childhood stuttering. Apart from the obvious difference in age of onset, differentiating between the two disorders is often difficult..

How many speech samples do we need to obtain? What are they?

In Clinic: videotaping is important for major samples Samples must be long enough to get representative sampling of speech. Preferably samples of at least 200-300 syllables, larger the sample, more representative the data will be. Always report how many disfluencies, x in a sample of____. May want to present pressure dialogue to see how the client may respond to such pressures in the real world For reading sample, ensure passage is at or below client's level. (3rd grade + unless has a reading impairment) Outside samples Preschoolers: at home, playground, in preschool or day care School-age: in school (classroom, hallway, playground) Adolescents and adults: at work or in a phone conversation

Variability and Predictability of Stuttering

In the 1930s, interest in stuttering turned from its medical or organic aspects to social, psychological, and linguistic aspects Anticipation: Stutterers can predict which words they will stutter on in a reading passage They anticipate fricatives are their issue sound and they avoid it Consistency: Stutterers tend to stutter on the same words each time they read a passage Adaptation: Stutterers stutter less each time they read a passage up to about six readings

Incidence and recover without treatment

Incidence- A measure of how many people have stuttered at some point in their lives. About 5-8% for stuttering Recovery without treatment- Somewhere between 70 and 80 percent of children who begin to stutter recover without treatment She skipped this

Children who stutter may exhibit:

Increased disfluency rates in reading tasks because they cannot change the words to avoid moments of stuttering as easily as they can in conversation Disfluencies with physical tension and secondary behaviors. Make sure they read the title If they miss the title or other words your syllable count goes down

Types of otherdisfluencies

Interjection Revision Postponement Hesitations Unfinished words/ abandoned

Interjections and Revision Definition

Interjection: Meaningless words irrelevant to the message. Can be sound/syllable interjection, whole word interjection, or phrase interjection {um/like/well/uh e.g., "I want um the red one."} If an interjection is used as a starter, or 3x or more, or used rapidly then can be considered a Stuttering Like Disfluency... Identify the WHY? Is it language formulation to bridge the gap? Is it word finding difficulty? Is it because they think they will get stuck and use it to hide the stutter? It could be normal example: somebody asks you a question and you say "um" Revision: Change in content, grammar, or pronunciation of a message {"I want the blue...the red one."}

International Cluttering Association Formed in 2007x

International Cluttering Association Formed in 2007 Primary goal of the association is to increase awareness and understanding of cluttering, and to improve treatment and quality of life or people who stutter. http://associations.missouristate.edu/ica/

Why do you need to consider risk factors With children,?

It is important to be able to identify which children are going to need treatment, which ones are more likely to recover with maybe some minimum treatment and which ones are not really at risk for continued stuttering

Speech sample

It is important to distinguish if your speech sample is noting disfluent events or stuttering events. Your report needs to be specific as to what you are reporting. A comprehensive sample would include both! Report all disfluencies observed in the sample and then breakdown if they are considered "typical" or "stuttering-like" disfluencies.

Differential diagnosis

It is important to know which classification of stuttering the client presents with to guide treatment and make appropriate referrals to other specialists.

Can other types of communication problems accompany neurogenic stuttering?

It is not uncommon for individuals with neurogenic stuttering to experience several other types of communication impairments. These might include: Aphasia—complete or partial impairment in language comprehension, formulation, and use Dysarthria—errors in the production of the speech sounds, such as slurring of sounds and words that affect the intelligibility of the individual's speech Apraxia of speech—irregularities in the timing and inaccuracies in the movement of the muscles used in speech production Palilalia—speech disorder in which a word, phrase, or sentence may be repeated several times, generally with increasing rapidity and decreasing distinctness. Most frequently in patients with postencephalitic parkinsonism and patients with pseudobulbar palsy Biggie Almost could be a good sign of a neurogenic issue Anomia—difficulty in finding the appropriate word to use Confusion—uncertainty as to their own identity and that of others, their location, current time period, etc.

Onset for cluttering

It is unlikely to be detected until a young child begins to produce longer and more complex utterances (Raphael, 2007) They may circumlocte thoughts Onset is not usually recognized until about age 7

Variability

Keep this variability in mind so we don't fall into the trap of thinking that the client is not working hard enough if he/she stutters more in a given situation

Assessment for Feelings and attitudes for Preschool Children

Kiddycat (vanryckeghem, 2002) Behavioral style questionnaire (mcdevitt & carey, 1995) Impact of stuttering on preschoolers and parents (langevin, packman, & onslow, 2010)

Key aspects of child's development to guide decision-making (yairi & ambrose, 1999)

Language skills: syntactic organization, lexical access, phonological encoding, and speech sound development(bernstein ratner, 1997a) Motor skills: oral motor control, speaking and articulation rate, and coordination of movement (riley & riley, 1986) Temperament: child's emotional reactivity to his/her speaking difficulties and the ability to regulate any difficulties that arise (jones, choi, conture, & walden, 2015)

Children Likely to be Chronic Red Flags

Male Family history of persistence Stable or increasing number of slds within 1 year of onset Stable or increasing severity ratings by clinicians and parents Child is stuttering more than 1 year following onset (esp. Females) Stable or increasing occurrence of secondary movements Many (3 of greater) repetitions/iterations Rapid rate of repetitions Strong reactions to the stuttering by the child Concomitant leaning or communication problems Later onset of stuttering at ages 3-4 Delays in phonological development

Malingered stuttering

Malingering/ feigning is "when a person is faking symptoms of an illness or incapacity, usually for purposes of personal gain" (Seery, 2005) . All the symptoms exhibited are falsified Personal gain (Morrison, 1995) obtaining something desirable (money, drugs, insurance settlement) Avoiding something unpleasant (punishment, work, military service, jury duty) An individual intentionally produces the disfluencies in order for others to believe that he/she is a stutterer UNLIKE psychogenic stuttering whereas the individual involuntarily produces symptoms that are not 'real'

Historical context for the evolution of stuttering

Many of the concepts found in past theories occur again---often taking a different form in current theories as technological advancements provide increasingly more refined and sophisticated understanding of how humans produce language and speech

Stutterers may also experience __________(contextual factors): The icf for stuttering

May also experience negative personal and environmental reactions (contextual factors): Personal reactions: Affective reactions: feelings of frustration, depression, embarrassment, hopelessness, and especially shame Behavioral reactions: actions such as avoidance, tension, circumlocution, struggle, starter words Cognitive reactions: thoughts indicating low self-worth, self-confidence, self-efficacy, self-esteem Environmental reactions: bullying, discrimination by teachers, employers, exclusion from social groups, pressure from parents and peers Gotta think "How am I gunna get this person certified?" Paying for services

Assessment for Feelings and attitudes for Adolescents and adults

Modified erickson scale of communication attitudes (s-24) has been normed on stutterers and nonstutterers (andrews & cutler, 1974) The s-24 (guitar & bass, 1978; ingham 1979; young, 1981) Stutterer's self-rating of reactions to speaking situations (ssrss) (johnson, darley, & spriestersbach, 1952)

Situational variability

Moment to moment or situation to situation changes People stutter more (or less) in a situation because of how they think, feel, or react to the....... Person they are talking to Topic being discussed Activity they are doing Thoughts they are having while they are talking Experiences they had earlier that day or previously Specific words they are using People's reactions to their stuttering

Childhood Onset Stuttering

Most common fluency disorder; onset is childhood. It does not matter the age you are treating, but WHEN it began. Hallmarks: Repetitions, prolongations, blocks Links to genetic and neurophysiological etiology May be accompanied by secondary behaviors, physical tension, and/or negative reactions/emotions Improves under fluency facilitating conditions (choral reading, singing, adaptation effect-6 times, consistency effect) ICD-10: F80.81

Normal disfluency: ages 2-5

Most frequent disfluencies in the speech of children who stutter, in ranked order, were part-word repetitions, dysrhythmic phonations, and single-syllable word repetitions, whereas the most frequent disfluencies of children who do not stutter were, in ranked order, interjections, part-word repetitions, and revisions-incomplete phrases (yairi and lewis, 1984). Repetitions are more common in younger children; revisions are more common in older children

Need to consider for assessment....

Nature of the stuttering: developmental or acquired 1. Developmental stuttering 2. Persistent developmental stuttering (idiopathic) 3. Acquired stuttering (stuttering typically appears following some sort of injury or disease to the central nervous system) 4. Psychogenic acquired stuttering 5. Cluttering

Circumstances of onset

Neurogenic stuttering Usually related to a neurological episode Often other neurological signs or symptoms Developmental stuttering No neurological episode, signs or symptoms

Who is at risk?

Neurogenic stuttering can occur at any age; however, it appears more often in adulthood, and the highest incidence is in the geriatric population. Bc of strokes and brain damage This profile is quite different from developmental stuttering which is not typically seen as a result of brain damage and which most commonly appears in early childhood in children between 2 and 5 years of age.

Neurogenic Stuttering

Neurogenic stuttering is a fluency disorder that is a result of damage to the nervous system. In order to have neurogenic stuttering, the person must be someone who did not stutter previously and then had some damage to the nervous system; whether it was the brain or spinal cord. The person stutters as a result of the damage to the nervous system. It might occur following a stroke, brain trauma, surgery, or drug use. It may involve one or both hemispheres of the brain, depending on the damage that was done or where the stroke or lesion happens. There must be damage to the nervous system for neurogenic stuttering to occur. ICD-10: F98.5 Adult onset stuttering or R47.82 Stuttering following cerebrovascular disease

Some of the patterns that set the two apart include:

Neurogenic stuttering may occur at any point in the production of a word, rather than primarily at the beginning, as is common with developmental stuttering. Final position is more neurogenic in nature Neurogenic stuttering often occurs on any type or class of word anywhere in a sentence rather than being linked to content words such as nouns, verbs, adjectives and adverbs. Neurogenic stuttering may occur in any type of vocal behavior, including singing and repeating well-learned passages, such as the pledge of allegiance. The disfluencies may occur with equal frequency in any type of a speaking situation. Neurogenic stuttering is often not alleviated by the same conditions that significantly lessen developmental stuttering. These include choral reading, singing, adaptation (repeated oral reading of the same passage) or speaking while under auditory masking or delayed auditory feedback. The aforementioned patterns, however, are not universal for all individuals experiencing neurogenic stuttering, and patterns may vary widely across individuals depending on the nature of the neurologic injury or disease.

Other Behaviors

No physical tension or struggle No secondary behaviors No negative reaction or frustration No family history of stuttering She skipped thise entire thing

Normal disfluenccy characteristics : ages 2-5

Normally disfluent children don't react to their disfluencies; they seem unaware of them Factors that may increase normal disfluencies: Demands on language acquisition Delayed speech motor skills Stress Competition and excitement when speaking Do not qualify for therapy unless it persists or gets worse Younger preschool children: borderline stuttering, ages 2-3.5

Other concerns

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?

Onset

Onset for stuttering is typically 2-5 years (yairi & ambrose, 2013); reported that the average age of onset is 3.5 years and 95% of pws start stuttering before age 4. Word bursts- vocab bursts If you have a client who has soft signs then tell the parents that they may outgrow it Always set follow up and give strategies Try Indirect treatment!

Reading sample

Oral reading measures may not be valid for children who stutter, as fluency breakdowns will slow reading rate. Reading slowly may be perceived as a reading problem, even though the underlying cause is disfluency. The validity of reading assessment tool for children who stutter is questionable, because it is difficult to differentiate the cause (decoding or stuttering) of oral reading fluency problems. Alternative measures of reading fluency, such as tests of silent reading fluency, may be more valid measures for children who stutter If the kid has a reading problem- is it the stuttering that is giving them the reading problem or is there really a problem

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

Episodic variability

Periods of episodes of having increased difficulty with their speech that can last for days, weeks, or even months. Likewise, they can also go through periods of increased speech fluency that can last for varying lengths of time Of course, increases in fluency may be viewed as good news. At the same time, we have to be careful not to become over-confident, assuming too quickly that the child no longer needs speech therapy

Risk factors for young children who stutter (yaruss & reeves, 2017)

Positive family history of stuttering - if you have one person in a family who stutters, chances are 60-70% that you will find another person in the family who also stutters. Girls are more likely to recover than boys; however if the child is a boy, he is more likely to continue stuttering Time since onset > x months (exactly how long is still under debate - I use 6 months) Child has language / motor mismatch: advanced language skills & typical/lower motor skills or advanced motor skills & typical/lower language skills Look at lang and motor Child has concomitant speech/language disorders (indicates a fragile language or motor systems.) Child is highly reactive to mistakes or disfluencies (esp. If the child is concerned about stuttering) How do they talk when youre with them Parental reactions are negative or fearful

Postponement, Hesitation, Unfinished Words/ abandonment

Postponements: Any behavior or technique used to avoid stuttering by pausing, delaying or stalling the attempt to produce a feared sound or word in the hope that the fear will subside enough to allow production Hesitations/Silent pause/Audible pause: silent pause of 1 second or longer Unfinished words/abandonment: A word that is abandoned and not completed later in the message {"I want the oran .... Red one}

Posturing and Respiratory

Posturing: This is one of the most common secondary behaviors associated with stuttering. It involves gesticulating usually used in an attempt to make speech. Some of these gesticulating features include; stomping foot, moving hands, trunk jerk, head turn, raising the eyebrows, etc. Most times these posturing behaviors become bad habits when they are displayed for a very long time. Respiratory: This is another secondary behavior associated with stuttering and it has to do with the respiratory pattern of the stutterer. This behavior involves fast or shallow breathing, breathing too often.

Prevalence

Prevalence- A measure of how many people stutter at any given time. It is used to indicate how widespread a disorder is. For stuttering it is difficult because you need agreement on what is "normal" and what is "stuttering" disfluencies. Parents do not always report accurately. Prevalence for stuttering (yairi & ambrose, 2013; craig et. Al, 2002) 2.4 % in kindergarten .72% in older children and adults *suggesting that many outgrow or stop stuttering with early intervention! Nice numbers that suggests you may not need them on your case load BUT they may be the person who doesnt recover Helps us know how to know who is chronic and persistant Family history Girls are most likely to recover

Blocks, Prolongations Clusters/Multicomponent

Prolongation: Of a sound; Duration of a phoneme (may include pitch rise and tension) {"I waaaaaaaant the red one."} Tension is never GOOD, face, neck, etc Block (Tense Pause): Of airflow or voicing in speech; Inappropriate timing for initiation of a phoneme or release of a stop element {"I want.....the red one."} Cluster/Multicomponent: Combination of disfluencies right in a row (cluster) { I I I waaaaaaaant uh the red one."} Word rep, prolongation, Interjection There are 3 disfluencies and since they're in a row then its even more of a red flag

May need a consultation with another individual

Psychogenic- Go to a physiatrist Sometimes you may need other professionals Check school personel

What could dysfluent speech be a sign of?

Reading disability Cluttering Apraxia Word finding issues ADHD Could aslo mean NOTHING!

Reading Material should be

Reading material used should not be aimed at challenging the client; it should be a grade level lower than their reading ability. Ssi-4 suggests at least a third-grade level requirement.

Similarities and difference in assessing early childhood and school-age children who stutter

Reasons for many of the differences are understandable: due to their still-developing linguistic, social, and cognitive skills, younger children need more support from the clinician and parents In contrast, younger and older speakers are similar in the assessment of speech behaviors. The same factors that affect the evaluation of speech samples occur for all ages The challenges: inherent in obtaining representative samples, ensuring measurement reliability, and the link between the observable stuttering behaviors and the true impact of stuttering on the speaker's life

Recovery Without Treatment

Referred to as "spontaneous" or "natural" recovery Recovery without treatment has long been a puzzling issue. 20-80% of cases will recover without treatment (bloodstein & ratner, 2008; andrews et al., 1983). This pertains to children Research at university of illinois (yairi & ambrose, 2005) over the past 20 years indicates that there are several factors that are useful for indicating that the likelihood that a child's stuttering will persist rather than disappear naturally.

Final word on risk factors

Remember that these risk factors are not definite determiners of who will continue to stutter (or who will need treatment) they are simply predictions based on presumed likelihood. Even children with family history can recover! By considering these factors in our diagnostic evaluation, we can make a reasonable prediction about whether the child is likely to recover on his own - and if he is not, we can feel more confident recommending treatment!

Measurement procedures Transcript based analysis:

Requires you record data and analyze it later, often based on a detailed verbatim transcript of the client's speech Could be video or audio These measures are time-consuming, but allows much more detail to be considered in analyses

Assessing feelings and attitudes

Results from the OASES and/or other profile scale can serve as a baseline for the affective/cognitive components Chrildren may be initially hisitant tot alk about their stuttering emotions/ reactions

How does stuttering affect Rhythm and Effort

Rhythm - the rhythmic pattern of speech which depends on intonation, stress pattern, timing, and duration. Example: People who with this disorder have disruptions that are louder, longer, and slightly higher pitched. This is what makes disfluencies more noticeable. Effort - how much mental or physical work it takes to talk. Normal speech is not effortful. If you see tension in anything- its not normal. If you only saw 1 disfluency then look into it Example: People with this disorder use more effort to talk because they're trying to sound "normal." It takes mental effort to think ahead of time about what words you'll get stuck on. It takes physical effort to stop or "escape" getting stuck on a word.

Learned Reactions and the 2 broad classes

Secondary behaviors are learned behaviors that are triggered by the experience of stuttering or the anticipation of it. Secondary behaviors can be divided into two broad classes: 1. Escape behaviors occur when the speaker is stuttering and attempts to terminate the stutter and finish the word (e.g.. Eye blinks, head nods, interjections of extra sound, "uh"). Escape behaviors occur AFTER stuttering has began 2. Avoidance behaviors occur when the speaker anticipates a stutter and tries to avoid it by, for example, changing the word said. e.g., postponements, starters, substitutions, and timing devices such as hand movements timed to saying the word.Avoidance behaviors occur BEFORE the stutter begins

Various speaking situations

Setting Task Partner Time Emotional state

The Best Estimates of Chronicity

Sex of child, as boys are at higher risk for persistence of stuttering than girls (craig et al., 2002; yairi & ambrose, 2013); Family history of persistent stuttering (kraft & yairi, 2011); Time duration since onset of greater than 6 to 12 months or no improvement over several months (yairi & ambrose, 2005); Age of onset-children who start stuttering at age 3½ or later (yairi & ambrose, 2005); Co-occurring speech and language impairment (ntourou, et al., 2011; yaruss et al., 1998).

Older children considerations Avoidance?

Situational anxiety: where certain speaking situations are more difficult for them to talk in than others. If this is happening, then gear treatment toward working on those specific situations. We want to be sure stuttering does not affect their participation of communication.

Therapy techniques that help reduce the symptoms of developmental stuttering may also be effective with neurogenic stuttering.

Slowing speech rate (saying fewer words on each breath by increasing the duration of the sounds and words). Emphasizing a gentle onset of the start of each phrase (starting from a relaxed posture of the speech muscles, beginning with adequate respiratory support, a slow and easy initiation of the exhalation and gentle onset of the first sound). Emphasizing a smooth flow of speech production and use of relaxed posture, both in terms of general body posture and for specific speech production muscles. Identifying the disruptions in the speech patterns and instructing the client in the use of more appropriate patterns.

Types of Repetitions

Sound Rep Syllable rep Word Rep Phrase rep

Sound and syllable rep

Sound rep: repetition of a phoneme that does not stand alone as a word {"I want the r r r one."} Syllable rep: More than a sound repetition and less than a word repetition {"I wan wan wanted the red one.} If needs to be more that one syllable ^ These red ones are more of a red flag

Typical-Like Disfluencies TLD)

Speech Characteristics Multisyllabic whole-word and phrase repetitions Interjections Revisions

Stutter-Like Disfluencies (SLD)

Speech Characteristics Sound or syllable repetitions Prolongations Blocks Clusters/multicomponents

"Normal" fluency

Speech flows easily and smoothly in terms of sound and information No disruptions in the sequence of sounds and words. Smooth transitions from one movement to the next The listener can attend to the message rather than considering how the message is being produced Look for tension-tension- BAD Could be a soft sign for apraxia

Comprehensive evaluation would also include...

Speech sound production Oral motor abilities Expressive/receptive language Lexical access Narrative abilitty

Starters and speaking rate

Starters: Words or sounds used by someone who stutters to get started speaking when blocked or when anticipating a block Speaking rate: How fast a person talks, usually with short pauses included (articulation rate is with the pauses removed). Speaking rate is most often measured in syllables per minute

Secondary Behaviors

Stutterer acquires as learned reactions to the basic core behaviors One of the problems with these secondary behaviors is the fact that they usually help to build fluency at the initial stage Posturing, Respiration, Facial, Vocal, Syntactic and Semantic

The Words We Use

Stutterer or Stammerer- Regional- Synonymous PWS (Person who stutters) verse PWNS Disfluency OR Dysfluency?-Believes in I Disfluency indicates the fluency break of normal speakers "I like um like" I Y signifies you have a problem

Explaining cause to parents

Stuttering arises due to an interaction among several factors that are affected by both the child's genes and the child's environment (motor skills, language skills, temperament) An interaction among factors contributes to the likelihood that the child will produce speech disfluencies and react to them.

Theoretical Perspectives Constitutional factors:

Stuttering as a disorder of brain organization Stuttering as a disorder of timing Stuttering as reduced capacity for internal modeling Stuttering as a language production deficit Stuttering as a multifactorial dynamic disorder

What we know as to the underpinnings of childhood onset stuttering......

Stuttering has been linked to genetic mutations in 4 genes: gnptab, gnptag, nagpa, ap-4. Mutations in these 4 genes are suggested to explain the cause for up to 20% of persistent stuttering cases (drayna et. Al, 2017). Twins studies and adoption studies provide further evidence that stuttering has strong genetic links. Concordance of stuttering is much higher in identical twins (52-57%) than in fraternal twins (12-31%) (drayna et. Al, 2017). Identical twins share similar dna and therefore demonstrate the genetic link. Fluent speech depends on well established connections among brain regions that support auditory processing, motor planning, and motor execution. These areas are connected through a white matter tract called superior longitudinal fasiculus. Pws are shown to have disruptions to white matter tract and functional differences with other deep brain structures (e.G., basal ganglia, thalamus, cerebellum). Pws often use more and/or different parts of their brain when they talk. Other personal and environmental factors might also play a role.

What we know as to the underpinnings of childhood onset stuttering......

Stuttering is likely multifactorial with strong links to genetics and neurophysiology (how the brain works) Not psychological Not caused by anxiety or nervousness although these can contribute to an increase in stuttering Not a learned or imitated behavior

Cluttered Speech!

Stuttering is rooted in sound repetitions Cluttering is more so prolonging and disfluencies If it is not stuttering, what else can it be? Disfluencies can arise as a normal by-product of mistakes that a speaker makes in the complicated process of planning and producing speech Systematic difficulties: language formulation impairment; word-finding difficulty, poorer syntactic abilities Childhood apraxia of speech Learning disability Reading difficulty

Neurogenic Stuttering

Stuttering typically appears following some sort of injury or disease to the central nervous system i.e. the brain and spinal cord, including cortex, subcortex, cerebellar, and even the neural pathway regions. These injuries or diseases include: Cerebrovascular accident (stroke), with or without aphasia Head trauma Ischemic attacks (temporary obstruction of blood flow in the brain) Tumors, cysts, and other neoplasms Degenerative diseases, such as Parkinson's disease or multiple sclerosis Other diseases, such as meningitis, Guillain-Barré Syndrome, and AIDS Drug-related causes such as side-effects of some medications

Developmental

Stuttering with a gradual onset during childhood; presents as a dysfluency in the timing, patterning, and rhythm of speech

How to assess types of disfluencies

Stuttering-like disfluencies versus typical disfluencies? Stuttering-like = sound or syllable repetitions, prolongations, blocks; tend to produce 3 or >3 iterations. Associated with physical tension or struggle; negative reactions or frustration; avoidance behaviors; family history of stuttering Typical =whole-word and phrase repetitions, interjections, revisions, tend to produce 1-2 iterations; no physical tension or struggle; no secondary behaviors or negative reaction; no family history

Psychogenic Acquired Stuttering: Nature

Sudden onset, no previous history of stuttering Typically appears after prolonged stress or a traumatic event. The psychological disorder CAUSES the stuttering (e.g.,schizophrenia, multiple personality disorder, bipolar, etc.) Unlike malingering (faking to get something out of it), psychogenic stuttering is not a conscious behavior deliberately enacted May be accompanied by unusual secondary behaviors May occur as lone symptom or accompanied by psychological or neurological signs Not the same as the anxieties that people with developmental stuttering might develop over time Primary disfluency is rapid initial syllable repetition

Stuttering in Military Personnel as a Result of Combat Injuries and Stress

Sudden-onset stuttering can result from TBI or PTSD as the result of combat injuries and/or prolonged stress Not always possible or necessary to differentially diagnose neurogenic from psychogenic stuttering in these individuals Important to listen to client's complaints, take them seriously, and help them understand why stuttering may have occurred under these situations Treatment may begin with trial therapy focused on relaxation of tension present in stuttering Treatment should first achieve fluency via relaxation or another fluency-inducing strategy focused first on vowels, then words, then sentences, and finally conversation Generalization can be achieved via specific transfer activities as well as group therapy Supportive psychotherapy may be an important adjunct to stuttering therapy

how to examine Speech rate

Tape record during oral reading or connected speech Use a stop watch to time the speaking sample Time only when the client is speaking; turn off when the student stops talking or when you talk. Use clicker or mark with a pen # of stutters during the timed period Divide # of stutters by # of minutes to get stuttered words per minute (swpm) Example: 10 stutters in 1 minute = 10 swpm 9 stutters in 2 minutes = 4.5 swpm

How is neurogenic stuttering diagnosed?

The SLP will want to seek input from the physicians involved in the clients' care. The evaluation will include consideration of the fluency problem and the individuals' case history, current medical status, and the presence of other communication impairments. If they're taking certain meds, some may cause stuttering -pharmagenic stuttering The diagnosis should determine whether the disfluency is neurogenic in origin and whether any other communication impairments are affecting fluency.

Summation: what we do know about

The cause of childhood onset stuttering? We cannot pinpoint the exact cause for every person who stutters but we do know that there is a strong link to genetics and how the brain works. Stuttering is gradually becoming more recognized as a "medical," not a "psychological" condition. The relationship between the observed genetic mutations and neurophysiological differences are not yet fully understood. It is only the beginning of this line of research!

The extent to which the stuttering is influenced by a concomitant disorder

The demands of language functioning for a person with a disabled cognitive system could contribute to the lack of proper idea formulation, word finding difficulties, and impaired syntactic processing of an utterance (Starkweather, 1987) Children with developmental delays often exhibit more than typical instances of stuttering, particularly children with Down's Syndrome (Manning, 2001) Children with learning disabilities/difficulties Children with Attention Deficit Hyperactivity Disorder Children with Autism Spectrum Disorder

Etiology

The etiology of stuttering is controversial. The prevailing theories point to measurable neurophysical dysfunctions that disrupt the precise timing required to produce speech. Over the years, numerous theories have been proposed to explain the etiology of stuttering. These theories have generally been representative of the prevailing beliefs of the time in which they were formulated. One's perspective on the cause of stuttering drives one's therapeutic approach.

Understanding adolescent and adults: the essential structure of unsuccessful stuttering management

The experience of stuttering may be characterized by a story dominated by struggle and suffering. Struggling to cope with the difficulties posed by the problem of stuttering, persons who stutter tend to lead a restrictive lifestyle dominated by attempts to avoid stuttering and to avoid revealing their stuttering to the world. These struggles, along with negative reactions from a variety of listeners, including family members, and failure associated with inadequate therapy can lead to emotions of helplessness, anxiety, low self worth, embarrassment, and disapproval and an overall life tenor of suffering. (2005, p 16)

Feelings and Attitudes

The experience of stuttering often creates feelings of embarrassment and frustration in a speaker Feelings become more severe as the speaker has more stuttering experiences Fear and shame may develop eventually and may contribute to the frequency and severity of stuttering Attitudes are feelings that have become more permanent and affect the person's beliefs Beliefs may be about oneself or listeners (hostility)

What is historical importance?

The most frequently asked question and often the first asked by clients, parents, and other professionals is...what causes stuttering? Your response matters!

Other indications of a possible psychogenic origin

The presence or a history of psychiatric disorders The presence of struggle behavior unrelated to speech production yielding the impression of "bizarre" speech. (motor patterns that are not usually seen in any other speech disorder) The observation that the stuttering worsens as the patient is given less difficult speech tasks The less difficult the task- the better the stutter, nope The most convincing support for a psychogenic diagnosis: symptom reversibility. Not unusual to find a dramatic improvement in fluency or even return to normal speech in response to behavior therapy after only two sessions or already during the diagnostic session

Assessing speech naturalness

The term "Speech naturalness" has appeared in the professional literature for more than fifty years Speech naturalness is a term defined from the listener's perspective as speech that "Sounds normal or natural" and allows the listener's attention to focus on the message rather than the speech pattern (parrish, 1951; nichols, 1966; martin, haroldson, & triden, 1984; ingham, martin, haroldson, onslow, & leney, 1985; onslow, hayes, hutchins, & newman, 1992) Use a 1-9 interval scale (1 =highly natural to 9 =highly unnatural) Speech-language pathologists have been primarily concerned with ratings of speech naturalness of adults who stutter before and after treatment because research has suggested that the stutter-free speech of posttreatment stutterers' remains perceptually distinguishable from the speech of normally fluent counterparts (love & jeffress, 1971; runyan & adams, 1979; finn, 1997; dayalu & kalinowski, 2002

A speech and language assessment is indicated when one or more of the following are observed in conjunction with disfluencies

There a family history of stuttering or cluttering. The child exhibits any negative reactions toward his or her disfluency. The child exhibits physical tension or secondary behaviors (e.g., eye blinking, head nodding, etc.) associated with disfluency. Other speech or language concerns are also present. The child is experiencing negative reactions from family members or peers. The child is having difficulty communicating his or her message in an efficient, effective manner. There is parental concern.

Neurogenic Stuttering Information

There is also an interesting symptom called "final sound dysfluency" seen in neurogenic stuttering. If a child repeats the final sound of words (e.g., "I went to the store-ore-ore"), it really stands out. From my experience, final sound dysfluency can occur for a few reasons. I have seen this occur in children with Tourette's, obsessive-compulsive disorder (OCD), and autism spectrum disorder. I have also seen it in children who just have stuttering when they are really blocking on the next word but are using the final part of the previous word to springboard themselves into the next word. "I went to the store-ore-ore-ore to get some milk" is very different than, "I went to the store-ore-ore." In the second case, nothing is being said after the word, "store." That was not just word-final dysfluency; it was an utterance-final dysfluency. It suggests that this is not someone who is stuck on the next word and blocking; rather something else is going on. That should send a red flag to start looking for characteristics of other neurogenic, autistic or OCD mannerisms. One of the other interesting findings is that someone with neurogenic stuttering often has some other speech and language component. If there is damage to neurological system to the point where it is causing the person to stutter, it is also possible that it is affecting speech sound production and language. Being able to weed that out and separate what component is based on the dysfluency, what the speech component is, and what the language component is can be helpful. For someone who has a neurogenic etiology, you may see all three of those issues and will work on all of them in treatment.

Adaptation effect

There is no real adaptation effect. The adaptation effect is when a person is given the same passage to read over and over again; he/she will stutter less and less with each reading.

Why are studies important?

These studies opened the door to new treatment possibilities. If much of stuttering is learned, it may be unlearned. The challenge is to determine HOW much is learned and how to help people who stutter develop NEW responses.

Who world health organization (who)

This is our medical guiding body Who adopted the international classification of impairments, and disabilities, and handicaps (1980) to describe the consequences of various diseases and disorders. In 2005, who changed their taxonomy to the international classification of functioning, disability, and health (icf) (who, 2001): The disability of stuttering is the limitation it puts on individuals' ability to communicate

Limitiation

This limitation is affected by the severity of stuttering as well as stutterers' feelings and attitudes about themselves and how listeners have reacted to them The handicap is the limitation it puts on individuals' lives (education, socialization, personal relationships) This refers to the lack of fulfillment they have in social life, school, job, and community The icf supports the need for a comprehensive assessment of stuttering Stuttering therapy can take along time, teaching them fluency and also teaching them to be comfortable Insurance needs to see any issues and ways that stuttering can effect Look at cognitive and

Frequency of disfluencies

Track how many times the client produces disfluencies of various types compared to the total number of words or syllables produced in the sample Can be tracked through a real-time and/or verbatim transcript Didnt touch

Neurogenic

Typically the result of a nerve of traumatic brain injury

All clients come from somewhere

Typically we inherit our school age clients from other clinicians We inheret their eval data We inherit their treatment goals We inherit their treatment activities What does this mean for us slide Making the most of the initial contact slide Is it going to be warranted?

Stuttering varies

We view variability in terms of: Episodic changes that people who stutter experience over time or from day to day Kids may get "wacky" when they get excited Situational changes that people experience in different communication settings Talking to men

Create case history questions When did you notice this..

What Prescription and Non-Prescription Medications Do You Take? ... What Allergies Do You Have? Family history? Specific situations where stutter gets better/worse? When did it start?

Less likely to recover

When a child stutters 80% can usually recover on their own 1. Family history: having relatives who were persistent stutterers 2. Gender: being male in adults 4:1 and in pre-k 2:1 which suggests males are at increases risk to continue to stutter based on gender. If after a year of onset she's less likely to recover than the boy 3. Age at onset: stuttering onset after 3.5 years increases risk (yairi and ambrose, 2005) 4. Stuttering frequency and severity is not decreasing during first year after onset is at greater risk 5. Stuttering persisting beyond one year after onset (especially girls) 6. Multiple unit repetitions more than 3 and rapid units (li-li-li-li-like this) We usually don't repeat something more than 3 times 7. Continued presence of prolongations and blocks (they don't decrease as stuttering goes ) Blocks are NEVER normal 8. Children whose phonological skills are below the norms

Sets the stage for things like advice

When giving advice to parents on stuttering onset and development, use yairi and ambrose (1999) longitudinal research results which found 74% of children recovered from stuttering without any treatment and 26% of children persisted in stuttering. The duration of stuttering tended to run from 6 to 35 months for most children who recover; however, they revealed that the children in the persistent group stuttered from 49 to 131 months (yairi and ambrose, 1999) .

Word and Phrase Rep

Word rep: Repetitions of a whole word {"I I I I want the red one."} (this has 3 repititions) Becomes an issue after 3 repetitions Phrase rep: Repetition of at least 2 complete words of the message {"I want I want the red one."}

Do all cultures have stuttering?

Yes! Stuttering is ancient and universal It has been a problem for at least 40 centuries!

Take home messages

You are not alone for there are millions of people who stutter who are facing the same problems when communicating. With determination and persistence you will be able to use strategies that will improve your fluency and quality of life. Along with a dedicated clinician and the support of others you will increase your confidence and enjoyment when communicating with others Always provide information to the client/parent/spouse/caregiver to properly inform and give access to support system

What can assessment result in?

You have your eval- you give your impressions Recommend therapy or dont Why wouldn't they need to? If they're part of that percentage as a child you could wait -Peak age 3 If their motivation is very low/ the adults have to essentially change all their patterns- How much are you going to be up against?What if they sat there and say that you have to cure them- they may think they don't need it Do Are they going to benefit? Determine WHO framework Make recommendations for actual treatment May need a consultation with another individual Psychogenic- Go to a physiatrist Sometimes you may need other professionals Check school personel

An slps response sets the stage

Your response as the slp sets that stage. You want to instill confidence in assessment and treatment. The slps understanding about possible etiologies of the problem will have an influence on the treatment decisions. The slps explanations concerning etiology will also influence the parents' response to their child, including how they deal with any guilt or shame they associate with their child's speech and how they respond when their child speaks fluently or stutters. It is important to have an opinion on etiology but to suggest we know in any absolute fashion would be ethically and professionally dishonest. The current thrust toward evidence-based practice demands that clinicians take a position and provide an objective rationale for their treatment regime.

Define stuttering

a disruption in the forward flow of speech that can take many forms, but it may also be accompanied by physical tension, secondary behaviors, negative thoughts and emotions, or decreased communication skills (coleman, 2015).

Task:

collect data during different speaking tasks (retelling a story, describing a picture or a toy/game, play interactions, engage in conversation)

Setting:

collect data in more than 1 setting to observe the variability of stuttering behaviors Classroom Sporting event Different setting- different confident levels Daycare

Partner:

collect data with different partners(family, peers, teachers, unfamiliar partner)

Truetalk:

counts syllables and stutters, as well as time during which the counter buttons are pressed.

Severity of disfluencies:

describes the physical behaviors during the stutter (e.G., tension struggle). Severity measures combine several aspects of behavior into a single number score. In doing so, you lose some of the detail in the data you collected, but severity rating are widely used. Often obtained through measures such as ssi (riley, 1994) or stuttering prediction instrument (riley, 1981) Feels like a question to me

Time:

gather samples across time because of variability(more or less fluent on a given day) e.G., during eval, at home, before and after school/day care/work

Types of disfluencies:

helps distinguish typical interruptions from "stuttered" interruptions; provides indication of the development of the disorder (especially in preschool children)

Frequencies of disfluencies:

how often disfluencies occur in a sample; typically represented as the percentage of disfluent words or syllables

Duration of disfluencies:

the number of seconds a repetition, prolongation, or block lasts or number of iterations in a repetition (e.G., "li-li-li-like contains 3 stuttered and 1 fluent iteration).

Emotional state:

variations over time may relate to the client's experiences or emotional states throughout the day (e..G., rested, tired, upset, excited)

Daily's 12 indicators

•1. Poor awareness & poor self-monitoring skills •2. Telescopes or condenses words •3. Rapid rate with poor intelligibility •4. Lack of pauses between words; run-on sentences •5. Imprecise articulation (distorts & omits sounds) •6. Irregular speech rate; speaks in spurts •7. Interjections; revisions; many filler words •8. Compulsive talker; many circumlocutions •9. Disorganized language; trouble sequencing •10. Repetitions of multi-syllabic words & phrases •11. No excessive effort during disfluencies •12. Speech better under pressure