Stuttering

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about stuttering (stammering)

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A disorder of fluency
-more than just the speech event itself, impacts ones quality of life
*field of SLP intamitely related to stuttering

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some famous figures who stutter

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Aristotle, King George VI, Newton, Marilyn Monroe, James Earl Jones, Herschel Walker, Joe Biden, and Emily Blunt

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Facts about stuttering

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>universal but prevalence varies across cultures indicating some cultural effects
>about 1% of population in the U.S.
>male > female about 4:1, 2:1 in African American
>recurs in families
>seen more in bilingual children (this is not supported)

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facts about stuttering continued

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6. Both tend to stutter in identical twins, only one tends to stutter in fraternal twins
7. There is no common personality type across stutterers
8. 85% of children start between 2-5 years when they start combining words into phrases and sentences
9. It is claimed that 75-80% of children who stutter will recover spontaneously, but this is doubtful
10. Stuttering is NOT all the time

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fluency in relation to stuttering?

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Stuttering is a disorder of fluency. But fluency and fluency disorder are not synonymous with stuttering. Those terms encompass other conditions as well
e.g., aphasia, foreign language learning.

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what is fluency?

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 Rate and smoothness of speech
 Typical rate of speech is 14-15_ sounds per second or about 200 syllables per minute
 This rate is needed for effective communication
 This rate is unique to speech
 Nonspeech sounds cannot be deciphered at this rate

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fluent speech

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 Disfluencies do occur

 Types of Disfluencies
E.g., pauses, interjections, fillers, phrase and word repetitions

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stuttering

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• More frequent disfluencies
• Different disfluencies
E.g., sound and syllable-level repetitions, prolongations, blocks

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stuttering...

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 Although we recognize it especially when it is severe, it is variable in its manifestation
 Be aware of covert ____?_____ that may affect severity, e.g., avoidance, circumlocutions

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definition of stuttering
-various manifestations
-no one definition is accepted using Wingate for now

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1. actual event or core features (speech events)
2.accessory features (physical concomitants)
3. precense of ? state

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1. Actual event or Core features (Speech Events)

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• Involuntary, audible or silent repetitions (e.g., pa-pa-papa or no sound) or
• Prolongations (e.g., s-s-s-snake) of short speech elements, such as sounds and syllables.
• These occur frequently or are marked and are not readily controllable.

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2. Accessory features: Physical Concomitants

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 Overt - eye blinks, facial grimacing, head jerks, exhalations
 Covert - circumlocutions, that appear to be speech-related struggles and coping reactions by speaker to the stuttering event.

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3. Presence of an ______________ state

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• Excitement or tension, or negative like fear, embarrassment.

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fluency inducing conditions

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Occasions when stuttering rarely occurs are referred to as Fluency Inducing Conditions (FICs)

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Fluency Inducing Conditions (FICs)

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1. Chorus speaking: Reading with at least one another person
2. Talking to a measured beat, e.g., metronome
3. Delayed Auditory Feedback (DAF)
4. Auditory masking
5. Other conditions, e.g., singing, whispering, automatic speech, talking to pets or young children

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East Carolina Device Speech Easy

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 Pitch alteration of own voice + DAF
 $2500- 4500 - yikes!
 Some may find it useful for the short-term along with speech therapy; no long-term effectiveness noted (across 4 months)

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when does stuttering increase?

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 Talking on the phone
 Telling jokes or saying one’s name
 Public speaking
 Talking to authority figures
 Any situation the speaker considers to be very important
 Speaking in ____________ stuttered situations

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3 main causes of stuttering

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 Organic
 Environmental
 Multifactorial

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theories of stuttering

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1. Cerebral Dominance Theory
2. Biochemical and Physiological Theories
3. Genetic Theory (nsastutter.org)
4. Neuropsycholinguistic Theory
5. Diagnosogenic-Semantogenic Theory
6. Neurotic Theories
7. Conditioning Theories
8. Contemporary Rx in Stuttering

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Cerebral dominance theory

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>Organic (seen as underlying neurolophysiological or biological)
>neither side of the brain is dominant controlling motor activities involved in talking
>positron emission tomography (PET) show differences in the brain of those who stutter and those who dont

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Biochemical and Physiological Theories

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>organic
>covulsion disorder related to epilepsy with siezures that could be triggered by emotional stress
-possibly something to do with blood-sugar imbalances observed

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Genetic Theory

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>organic and enviromental
>possibly number of genes hard to examine because of confounding enviromental influences

-know that stuttering runs in families, but more empiracle genetic research is needed to increase understanding and this is complex to get

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Neuropsycholinguistic Theory

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>addresses production of fluent speech, stuttered speech, and nonstuttered speech disruptions
>requires linguistic symbol and paralinguistic (signal system)
>if dont add up then have breakdown

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continued...

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>Kolk viewed stuttering as disturbed interaction between phonological encoding and verbal self-monitoring

-need more future research to address these hypotheses

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Diagnosogenic-Semantogenic Theory

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>enviromental
>proposed by Johnson
>the diagnoses by parents creates the problem the child will speak abnormally due to the parents anxities
>research has been done do know that parents of person who stutter anxious, perfectionist, questions about dynamics, and whether calling attention results in disfluencies

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Neurotic Theories

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>say cause of stuttering is number of different personality and psychological attributes of stutters.
- through interviews, observation, projective tests, and paper-pencil tests attempts have been made
>discredited these views poor scientific evidence

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Conditioning Theories

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>classical conditioning breakdowns in speech fluency gradually become associated with speakers anxiety about talking
>operant conditioning modify behavior through cnsequences occur after it.
-Flanagan, Goldiamond and Azrin demonstrate stuttering responds to procedures punished or rewarded

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Contemporary Research

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>organic
-show differences in areas of the brain
-tend to rely more on right side

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multicultural theories

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 Combination of several factors results in stuttering, e.g., speech motor control, genetic, cerebral differences, etc.
 Popular

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Differential Diagnosis: Variations of stuttering and other fluency disorders

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1. Typical disfluencies
2. Adult-onset of Stuttering
3. Cluttering

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red flags of stuttering

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1. Multiple part-word repetitions
2. Prolongations
3. Schwa vowel, e.g., buh-buh-buh-baby rather than bay-bay-bay-baby
4. Struggle and tension
5. Pitch and loudness rise

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red flags of stuttering continued

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6. Tremors
7. Avoidance
8. Fear
9. Difficulty in starting or sustaining airflow for speech

 All signs do not have to be present.

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Adult onset of stuttering

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1. Recurrent: Individual stuttered previously in childhood
2. Psychogenic: Very rare; Associated with some psychological event
3. Neurogenic: Occurs after some neurological damage
4. Pharmacological: Side effect of __________, e.g., antidepressants

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more about adult onset

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 May need to conduct some supplemental Ax and Ix, e.g., aphasia testing and Ix for neurogenic stuttering, besides standard stuttering Ax and Ix
 Differential diagnose developmental disfluencies from stuttering

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cluttering

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 Again, several definitions exist like with stuttering
 Book, p. 171 - A disorder of speech and language processing that results in rapid, dysrhythmic, unorganized, and frequently unintelligible speech
 It often coexists with phonological errors, learning and language impairments, attention deficits, and stuttering

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Assessment Steps

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1. Referral Source – Provides initial statement of the problem
2. Case History
3. Description of Speech Behaviors
4. Description of Other Relevant Behaviors
5. Stimulability: Speech change probes
6. Decision making and Goal Setting

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Assessment: Case History

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Assists with differential diagnosis and prognosis
 Medical History
 Family history
 Age of onset_
 Length of stuttering
 Better or worse situations
 Functional impact of problem
 Reactions to Stuttering and Coping strategies

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Assessment: Description of Speech Behaviors

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3 X 3 X 3 Rule
 Observe speech in 3 situations
o E.g., school, home, clinic for child
o E.g., work, spouse, on phone for adult
 Collect at least a 3-min sample
 Collect over 3 weeks, if possible

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why are multiple observations needed?

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 Assess # of stuttered (what are these?) syllables and # of disfluencies (what are these?)

 Assess # of syllables per minute, regardless of stuttered or not
o Why is this needed?

 Assess Speech Naturalness
o Typically done using rating scales

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criteria to identify stuttering

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• Ten or more total disfluencies (typical+stuttered) in 100 words
• Three or more stuttering-like disfluencies in 100 words

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tests of stuttering

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• Stuttering Severity Instrument
• Not necessary

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Assessment: Description of Other relevant Behaviors

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 Obtain information about emotional consequences of problem
o If child client, ask parents about reactions to problem, e.g., teasing
 Informal assessment of ______________ status, speech (e.g., articulation), and language to rule out any co-existing problems

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Assessment: Stimulability Testing or Dynamic Assessment

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 Children
o Reinforcement – Reward for fluent speech
o Punishment (“oops”) – Behaviors we do not want children to do
o “Easy Speech” - e.g., Gentle articulation and sliding into words

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Assessment: Stimulability Testing or Dynamic Assessment

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 Adults
o Rhythm
o Prolonged speech

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Assessment: Decesion Making and Goal Setting

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 What decisions do you need to make?
 What goals might you set?
o E.g., Johnny will demonstrate the ability to reduce the number of disfluencies in his speech by using easy starts at the beginning of sentences 85% of the time in a structured conversation.