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| Class: | CSED 6630 - Fluency Disorders Child-Adults |
| Subject: | Communication Sciences & Disorders,... |
| University: | Idaho State University |
| Term: | Fall 2010 |
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Positive Regard
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optimism, excitement in the process, confidence in knowledge, willingness to take risks, share ourselves, venture into unknown, focus on the client |
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Characteristics of SLP communication style
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animated, attentive, friendly, contentious |
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Successful Clinician Qualities
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empathy, warmth, genuineness, ability to listen, ability to adjust, ability to make correct observations |
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Manning's important clinical success
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knowledge of characteristics of disorder, willingness to connect with the client, knowledge of treatment methods, ability to identify specific characteristics of a specific client |
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competency
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open mindedness and flexibility, ability to admit errors, recognize strengths and weaknesses, demonstrate respect and compassion, learn from each new case, call on others for help and information |
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chances of not stuttering
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by 5 years 25% by 8 years 50% by 10 years 75% if they haven't started stuttering by 12, then they most likely will not (except neurogenic causes) |
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operational definition
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tells what to look for during diagnosis this is the core behavior(s) |
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Important aspects of Wingate's definition
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disruptions of fluency, disruptions occur in verbal expression, disruptions are involuntary, involve silent or audible repetitions, involve silent or audible prolongations, involve "broken" words, silent prolongations are called blocks, disruptions occur frequently, learned behaviors can accompany these disruptions (struggle), negative emotions accompany all of the above |
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Root of Stuttering (according to Peters and Guitar)
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neuromotor and complex language |
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Conture's definition of Stuttering
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diagnostic label referring to a clinical syndrome with abnormal and persistent disfluencies accompanied by characteristic affective, behavioral, and cognitive patterns |
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Manning's definition of Stuttering
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behavior w/involuntary breaks in sequence of motor movements necessary for verbal communication tension and coordination issues are present from larynx and up |
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Curlee and Seigel's definition
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complex, multilevel, and dynamic processes interact to produce fluency failures that are unacceptable to the individual and his/her culture |
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Hutchinson's Definition
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disfluency of verbal expression characterized by 1-repetitions of linguistic units; 2- abnormal prolongations of articulatory and/or laryngeal posture; 3- and/or interjections or extraneous sounds or syllables Core behaviors: repetitions, prolongations, interjections |
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Differences between Wingate and Hutchinson
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-little or no agreement between the two -Wingate: does NOT allow mulit-syllabic word repetitions NOR interjections as disfluencies; creates new category called "broken" words -Hutchinson: ALLOWS for multi-syllabic word repetitions AND interjections as disfluencies |
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Stuttering and Iceberg
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can see overt features of stuttering (verbal) but 90% of the iceberg is below the waterline: fear, hopelessness, loss of control, etc. |
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3 Blind Men w/the elephant and Stuttering
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the way in which you define depends on which part of the disorder you get a hold of and what it will consist of |
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ABC's of Stuttering
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Affective- feelings and emotions Behavioral- observed characteristics Cognitive- attitudes about their stuttering (kind of overlaps with A) |
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Prevalence and Incidence
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-generally accepted to be about 1% of the population at a given time -population that has stuttered at one time: 5%, 75% recover without intervention |
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Sex Ratio
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3 males to each female (SA and Adult) 1 to 1 in preschool population |
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Onset Age
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-coincides with multi-word utterances (18 months) -typically before puberty -mostly between 2 and 5 years of age |
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Predictability and Variability
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-constantly variable but highly predictable -predictability may be a clue to the disorder -stuttering is individualized and inconsistent -there are aspects that are predictable across the disorder |
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Where does Stuttering Occur?
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on consonants, initial sound of a word, contextual speech, nouns, verbs, adjectives, stressed syllables, NOT when swearing |
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Are Interjections Stuttering?
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not agreed upon most frequent disfluency in all of us depends on frequency of occurrence <5% of spoken material is normal >5% of spoken material is stuttering |
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Multisyllabic word repetitions stuttering?
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like interjections- not agreed upon tend to occur with all of us depends on frequency <5% of spoken material is normal >5% of spoken material is stuttering |
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variability and stuttering
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people who stutter are variable- -do not stutter on the same sounds, syllables, or words all the time |
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predictability/anticipation and stuttering
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people who stutter can predict the words on which they will stutter |
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Consistency and stuttering
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people who stutter will stutter on the same words across multiple readings of the same passage |
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Adaptation and stuttering
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stuttering frequency decreases with repeated readings of the same materials |
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Fluency enhancing conditions
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alone, singing, speaking to an infant, speaking to an animal, shadowing another speaker, using a different dialect, simultaneously writing, when swearing, ***THESE DO NOT LAST- it is a good place to start to show they can be fluent- change in level at VC, change intonation, rhythm, prolonged vowels |
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Stuttering as Phonetic Transition Defect
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-PWS do not have trouble with certain sounds, syllables, or words per se -have difficulty getting off of sounds/words/syllables and onto the next sound/syllable/word (moving from one to the next) -perhaps the breakdown is in motoric system to make transition |
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Sound repetition
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s-s-s-s-s-s-s-sun |
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syllable repetition
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trans-trans-transportation |
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multisyllabic word repetition
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transport-transport-transportation |
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single syllable word repetition
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sun-sun-sun-sun-sun |
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prolongation
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audible prolongation: zzzzzzzzzzzzzzzz-zoom silent prolongation: assume articulatory posture for a sound but no acoustic output (a.k.a.: BLOCKS) broken word- special form of silent prolongation: begin to produce the word, part way through stop production and lose artic posture; resume word at point where artic posture was lost: bro.........ken |
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interjections
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intrusions of verbal or vocal elements into running speech verbal: you know, ok, alright, etc vocal: um, uh, er, ah, etc |
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struggle behaviors and accessory features
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-struggle behavior: produced w/repetitions and prolongations; -listener perceives that the speaker is struggling to speak -tight, forceful muscles -accessory features: learned behaviors: -allows PWS to avoid, postpone or escape from stuttering -e.g.: finger popping, head turning, odd body postures |
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Fluent Speech
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ability to move structures of vocal tract easily, rapidly, smoothly, and consistently with appropriate timing coordinated with other structures 8,000 muscles movements per minute to produce speech 175-275 words per minute (vs. PWS 75-175 words per min) |
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Stuttered Speech
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inability to move structures of vocal tract easily rapidly smoothly with appropriate timing coordination |
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Fluency vs. Disfluency
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-fluency is judged on rate and continuity -fluency is influenced by information load -ALL speakers experience decreased fluency at times -PWS vary in degree of fluency -PWS do not stutter at all times (actually more fluent than disfluent) -disfluencies reflect a disturbance in smooth transitioning between sounds, syllable, and words |
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language variables and fluency
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1-syntax: ease in constructing sentences w/complex linguistic structure 2-semantics: ease of retrieval of vocab 3-pragmatics: knowing and demonstrating correct pragmatic features 4-phonological: ease of production of complex strings of sounds ***stuttering is related to production of strings of sounds (#4) |
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Normal Non-Fluencies in Children
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-2-5 years of age -transient (not disfluent all the time) -periods of nonfluencies are temporary -nonfluencies are effortless (no tension) -nonfluencies are rhythmic- relaxed tempo/even pace of speech -repetitions of whole word and whole phrases -interjections, revisions, pauses, little/no awareness, no struggle, no tension *spurts in language/speech development *acquisition in other developmental skills |
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Normal Non-Fluencies in Adults
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some typical characteristics of the normal nonfluent adult: -phrase repetitions/revisions -formulative interjections (um, ok, you know) -pauses -low # of other types -slowed rate -short segment duration (breaking into small pieces) -lack of struggle -awareness but lack of concern -lack of effort in speech production |
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Normal vs. Stuttered Speech
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normal: multisyllabic word repetitions, phrase repetitions, interjections, revisions stuttering: sound repetitions, syllable repetitions, sound prolongations, broken words monosyllabic word repetitions could be either |
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Conture: NNF vs. Stuttering
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NNF: between-word disfluencies stuttering: within-word disfluencies |
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Formulative vs. motor breaks
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formulative (normal): breaks between words, phrases, larger syntactic units; lack of tension; interjections between words, phrases or larger syntactic units motoric: breaks between sound and syllables; tension in vocal tract; stoppages of airflow or voicing; prolongations of long duration |
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Between word disfluencies (Conture)
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Normal: transition difficulties between words difficulties linking words together phrase repetitions: i want i want i want the red one interjections: i, ummmmmmmmmmmmmmm, i want the red one **can occur due to: cognitive processes, motoric processes, coordination issues, distraction, language issues, phonological issues |
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Within Word Disfluencies (Conture)
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Stuttering: transitions within a word, difficulties linking components of words, disfluencies that break up the flow of words, repetitions, prolongations, blocks, broken words **can occur due to: cognitive processes, motoric processes, coordination issues, distraction, language issues, phonological issues |
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Van Riper on Differentiation
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based on: -syllable repetitions (break up words): vocal tension, interrupted air -prolongations: more than 1 sec, rise in pitch, sudden termination -silent pauses: within word, long prior to speech initiation -phonation features (level of the larynx): inflections, vocal fry -artic postures: may be inappropriate -stress reaction: more broken words -evidence of awareness: frustration, eye contact may waiver |
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Yairi on Differentiation
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based on: -part word and monolsyllabic repetitions -prolongations -dysrythmic speech -monosyllabic repetitions/pert word repetitions -sound repetitions -blocks |
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Influences on Stuttering
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-NNF vs IS: degree of awareness -onset factors: sex ratio, 1:1 preschool 3 males to 1 females age- begin stuttering earlier, younger =greater chance of stutter genetic- tends to run in families twinning- identical= both probably will, fraternal= 1, not other brain injury- sometimes develop stuttering speech/lang development- one gets ahead of other= difficulties motor coordination- language made visible temperament- tends to be children who are criticized/uncomfortable |
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Less influential Factors
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physical development illness imitation of someone else who is disfluent shock or fright (psychogenic group of stutters, not really kids) emotional/communicative conflicts socioeconomic factors nationality- universal behavior |
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Van Riper Track System
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Track 1: gradual onset (2.5-4 years); irregular reps; stuttering Track 2: SA/adolescent; hurried dysrhytmic repetitions; few prolongations; awareness/emotional reactions; little avoidance Track 3: (not true stutterers- didn't progress through childhood phases); sudden onset following trauma (psychogenic); prolongations; laryngeal blocks; awareness and frustration; intense avoidance; stuttering Track 4: sudden onset (5 to 9 yrs); deliberate repetitions (consciously controlling repetitions; no change in types; no avoidance; appropriate eye contact; stuttering |
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Conture's Development System
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4-way tract (more of a developmental scheme) ALPHA: brief, subtle disfluencies (more NNF); inefficiencies of speech production BETA: oscillatory repetitive movements; compensatory to alpha behaviors GAMMA: tense and fixed behaviors; compensatory to beta DELTA: verbal and non-verbal; Rxs to beta and gamma; pharyngeal |
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Guitar's States of Stuttering
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*NNF: behaviors w/in normal limits (<10 disfluencies/100 words); typical 1 unit reps; occasional 2 unit reps; interjects; revisions; wwr *Borderline Stutter: <10 disfluencies/100 words; more than 2 unit reps; rare reactions to stutter; do not consider themselves stutter *Beginning Stutter: (3-6 yrs) tension; pitch rise @ end of dis; no strong (-) feelings of self; accessory behaviors; more aware stutter *Intermediate Stutter: fear/avoidance; (6-13 yrs); blocks; escape to terminate block; fear b4, embarrassment during, shame after *Advanced Stutter: (14+ yrs); longer tense blocks; tremors appear; strong emotions- often helplessness |
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Speech Motor Function
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subtle differences between non-stutterers and CWS: -laryngeal function -laryngeal/respiratory/articulatory coordination -speech motor execution in speech |
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Phonological/Language Factors
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CWS are more likely to exhibit co-existing phonological delay or disorder compared to Non-stutterers |
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Assessment
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1- does fluency disorder exist or is client at risk? 2- determine type of fluency disorder (quantify and severity) 3- identify set of behaviors comprising disorder (neuro, stutter, clutter, psychogenic) 4- determine severity (imairment, disability, handicap, mild/mod/severe) 5- determine prognosis 6- assess progress- monitor, assessment gives baseline, ongoing every clinical session should evaluate for progress |
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Other Fluency Disorders
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-cluttering- language disorder -neurogenic stuttering- behavioral disorder (lesion to neuro structure) -psychogenic stuttering |
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Behaviors to look for in Assessment
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surface behaviors: observable, speech/secondary, qualify (about severity), quantify (anything you can count- # of reps, interjects, etc) intrinsic behaviors: below surface (iceberg), intrinsic to individual, insight to critical speech, what makes everyone different |
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assessment process
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*asking questions and gaining info- creates more questions (for every question, 5 more from answer) *making observations- gathers info to answers *important terms- assessment (not a diagnosis); diagnosis (statement we make based on info obtained) GOAL 1: who is and who is not a stutterer at a young age GOAL 2: differentiate whether neurogenic or psychogenic |
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adult assessment goals
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1- determine nature of disfluent speech (surface features) 2- info on history of problems 3-info on history of treatment 4- determine beliefs/attitudes about talking 5- what are their behavioral components 6- views of stuttering and what causes stuttering 7- views of self as stutterer 8- decisions made due to stuttering 9- avoidance behaviors 10- anticipation (what they do) 11- behaviors they're aware of 12- what they believe others think |
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Molar Analysis
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gives single number summary of stuttering; i.e. duration of the 3 longest stutters, severity: mild/mod/severe frequency, duration, severity, speech rate |
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Molecular Analysis
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takes stuttering apart into its constituent parts i.e.: certain % of prolongations, repetitions, broken words etc types of disfluencies, proportion of types, secondary behavior |
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Child Assessment Goals
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1- determine nature of disfluent speech 2-assessment of speech/lang. level-most need work on more 3- info on history of problem (from child AND parent) 4- info on history of treatment 5- determine beliefs/attitudes about talking 6-listen to child's and parents' willingness to talk about stuttering 7- behavioral components 8-awareness of what stuttering is 9- thoughts/beliefs about why he/she stutters 10-awareness of anything s/he does to control or help 11- level of worry/distress 12- perception on parents' worry/distress |
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Info to gather from Interview/Case History
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general development family history academic or work info presenting problem history of disorder reaction to problem precipitating factors (what situations give rise to stuttering) nature of disfluency (what does it consist of?) |
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Emotions and Attitudes
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important to gather info: *affects choices made *may narrow options *impact on treatment success *indication of severity *increases client understanding of disorder *to assist client in acknowledging aspect THINGS TO ADDRESS: beliefs about stuttering, beliefs about ability to control/manage stuttering, beliefs about ability to change, fear/shame/embarrassment, |
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Methods of Analysis (adults)
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1- Perceptions of Stuttering Inventory: determines attitude 2- Southern IL Uni Speech Situation Checklist: things to work in Tx 3-Stutters' Self-Rating Reactions to Speech Situations: use Tx 4-Self Efficacy Scale of Adult Stutterers: attitude/confidence/perform 5- Self Efficacy Scale for Adolescents: attitude/perform/confidence 6-Stuttering Problem Profile: help patient set Tx goals 7-Modified Erickson Scale of Comm Attitudes: patient's attitude 8-Locus of Control of Behavior Scales: attitudes/emotions |
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Methods of Analysis (children)
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1-What's True For You: self awareness of stuttering 2-Worry Ladder: see how much stuttering is mentioned 3-Write a Picture Word: attitude (+)/(-) 4-My View of School: attitude 5-Here's What I think: attitude/emotions 6-Hands Down: self confidence 7-Important Stuff about Me: attitude 8-What Pops: attitude/emotions 9-Framing my Speech: attitude/emotion 10-Draw a Picture: attitude/emotion |
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Speech Sample (children)
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*size: larger to represent behaviors (100-300 words/syllables) (Costello and Ingram): clinic: 10 min convo. w/parent, 10 min w/child; outside: 10 min w/parent; 10 min w/clinician; 10 min w/sibling/friend; 10 min in regular activity (Yarass): parent-child interaction; play interaction w/clinician- with and without stress; story retell; pic. description; reading (Hutchinson): convo w/clinician; convo w/parent; pic. description; story retell; reading; convo w/peer; convo w/teacher; convo about emotional topic |
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Speech Sample (adult)
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Size: 100-300 words/syllables (Costello and Ingram): clinic:5 min reading; 5 min convo w/clinician; 5 min monologue; outside clinic: 5 min convo w/clinician; 5 min w/spouse/frien; 5 min phone; 5 min school/work (Hutchinson): 500 words/syllables; convo w/clinician; convo w/significant other; reading; monologue; convo w/colleague at work; phone call; patient selected activities |
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HUSP vs. Yairi Profile Analysis
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**HUSP: molecular, 6 major categories (those broken into 15 subtypes), transcribe in normal orthography, place # above each moment of stutter that corresponds w/a subtype **Yairi: molecular, divides disfluencies into w/in word or between word |
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Things to Consider when Diagnosing
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history and reactions stuttering frequency types of disfluencies duration on moments of stuttering accessory and associated behaviors speech rate naturalnes of speech phonological skills language skills oral motor skills |
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NNF Characteristics
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<9% disfluencies whole word repetitions phrase repetitions interjections revisions <2 units per repetitions little or no difficulty w/airflow no schwa vowel intrusions |
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Stuttered Speech characteristics
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>10% disfluencies part word repetitions audible prolongations silent prolongations >3 units per repetition frequent difficulty in starting and sustaining airflow schwa intrusions persistent |
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Diagnosis for Preschoolers
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**based on: -speech sample analysis -assessment of awareness and concern -parent concerns/attitudes -child concerns/attitudes |
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MOST LIKELY require treatment
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total disfluencies= more than 10% sound prolongations= 30% disfluencies stuttering severity index score= more than 18 stuttering prediction index score= more than 16 majority of w/in word disfluencies= 65% or more clustered disfluencies duration= 0.5 to 1 sec awareness, concern, avoidance, expectancy associated behaviors |
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MAY require treatment
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total disfluencies= more than 6-10% sound prolongations= 12-25% of disfluencies stuttering severity index score= between 12-18 stuttering prediction index score= between 10-16 w/in word disfluencies= 40-60% occasional clustered disfluencies duration= 0.25-0.5 seconds may have awareness and occasional associated behaviors no negative emotions |
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who will NOT require treatment
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total disfluencies= less than 3-6% sound prolongations= less than 12% of disfluencies SSI score= less than 12 SPI score= less than 10 w/in word disfluencies= less than 40% typically no clustered disfluencies duration= <0.25 NO awareness, concern, negative emotions, associated behaviors |
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Positive Prognosis
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Child needs to have: -no history of unsuccessful treatment -cooperative parents -less severe patterns -little avoidance -cooperative teacher/school support -no other significant problems -intensive therapy options (2-3 times per week) |
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Diagnosis for Adolescents/Adults
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determine: -History of problem -Disfluency type -frequency -duration -associated behaviors -attitude and emotional info CONSIDER: predictability, persistence, consistency Benefit from: info on emotions/attitude, why seeking Tx? |
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Stuttering Therapy
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1- stuttering modification- decrease fear/avoidance 2-learn "easy stuttering"- in a relaxed, easy way and feel OK about it 3-fluency shaping- learn to be fluent in an easy context (single word or phrase level); maintain fluency in more and more difficult situations |
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Steps in Therapy
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Principles for working with fear: -fearless clinician -explore/approach feared object -maximize time in contact w/feared object- longer in stutter, more fear will decrease -explore beliefs in accepting way -explore what child feels he's doing when in a moment of stuttering, increase positive awareness |
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Stuttering Modification
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1-reduce avoidance 2-make therapy fun- be reinforcing and let them know they're doing great 3- reduce shame- want openness 4-stimulate approach, exploration, acceptance |
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cancellations
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powerful, relaxed slow motion stutter -hold onto stutter, slow motion on non-feared words -pause, say it in slow motion |
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pull outs
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you catch yourself IN the stutter and decide not to do that- -becomes just a "behavior" and have more control over it -facial expressions relax |
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preparatory sets
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person can sense when stutter is coming up -pauses, collects themselves before starting a word w/o being fluent -use on non-feared words AND feared words -by relaxing the face, VF are relaxed, etc. -uses proprioception as well as saying it slower |
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Fluency Shaping
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-not a lot of avoidance and fear (good for pre-schoolers) -use w/modification strategies -use natural fluency in linguistic hierarchy- words, phrases, sentences, conversation -learning a new pattern- a new way of speaking -slow rate: putting in pauses, saying syllables a little slower |
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easy onset
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bringing VF together gently, voiced sounds -way to start a word that has voicing in it so it doesn't trigger stutter -tend to get stuck in stop posture |
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light contacts
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keeping child from stopping -not to stop on sound- go through it in a way that doesn't stop |
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