Stuttering Assessment And Theory

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Stuttering Like Disfluencies

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Sound Syllable Repetition (SSR)
Whole Word Repetition (WWR)
Audible Sound Prolongation (ASP)
Inaudible Sound Prolongation (ISP)

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Other Disfluencies

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Phrase Repetition (PR)
Interjection (J)
Revision (REV)

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Total Disfluencies / Total Words

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> 10%

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Stuttering Like Disfluencies / Total Words

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> 3%

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Stuttering Like Disfluencies / Total Disfluencies

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> 66%

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Risk Factors for Persistence

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1. Gender (boys > girls)
2. Time since onset (12+ months)
3. Age of onset (>3)
4. Family History
5. SLD's and severity (stable or increasing?)
6. Phonological delays, concomitant cognitive or language difficulty

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Inidicators of Remission- Green Flags

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1. No relatives who stutter
2. Relatives who stuttered and recovered
3. Female
Decreasing pattern of SLDs within 1 year of onset
5. Decreasing severity ratings
6. Within one year of onset
7. Decreasing secondary movements

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Case History / Interview (with parent)

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1. Family History
2. Time since onset (use bracketing if needed)
3. Has the stuttering stabilized or increased?
4. Does child avoid situations or get frustrated?
5. Are there any physical concomitants?

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Case History / Interview (with adolescent or adult)

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1. What brings you here today?
2. How often would you say you stutter?
3. Do certain situations make you stutter more or less?
4. Tell me about the decisions you make throughout the day.
5. Have you ever been treated for stuttering?
6. Do you use any strategies to help you stutter less?
7. What are your expectations of stuttering treatment?

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Characteristics of Stuttering Onset

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-24-42 months of age
-Onset can occur over 24 hours (30%)
-Unusual or abnormal fluency breaks (including blocks, facial contortions, repetitions, and sound prolongations)

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Assessment of client's attitudes and beliefs

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-Educational impact
-Socio-emotional impact
-Independence
-Affecting intended message

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Point of Complaint

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*What do you do because you stutter?
-What do you do when you stutter?

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Pediatric Assessment Battery

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1. Case history / parent interview
2. Oral Mech
3. Test of Phonology (Bankston- Bernthal)
4. Semantic knowledge, Receptive Expressive Language Test (PLS-4)
5. Speech Sample
6. Communication Attitude Test for Preschool and Kindergarten Children Who Stutter (KiddyCAT)
7. Avoidance behaviors

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Adult Assessment Battery

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1. Case History/ Onset of Stuttering
2. Motivational levels
3. Patient stated goals
4. Surface features- duration, frequency, substitution, tension, avoidance, postponement
5. Intrinsic features- loss of control, cognitive and affective factors, restricted lifestyle
6. Locus of Control of Behavior Scales
7. Self-Efficacy Scaling for Adult Stutterers

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Linguistic Bases Def'n
Does it meet criteria?

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“Formulative fluency breaks are characterized by (a) breaks (usually in the form of repetitions) between whole words, phrases, and larger syntactic units and
(b) interjections between whole-word or larger syntactic units...
Formulative fluency breaks are the result of linguistic planning or uncertainty and provide the speaker with time to organize the remainder of the sentence.”

NO

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Fault Line Hypothesis (Linguistic)

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fluency failure arises from disturbance in construction of pre-articulatory plan, PWS have a phonological encoding deficit, syllable onsets retrieved on time, while the rimes are not– speaker can’t proceed past syllable onset

NO

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Covert Repair Hypothesis (Linguistic)

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Fluency failures result from efforts to correct phonetic errors prior to articulation. Presumes an underlying impairment, slow activation and selection of correct lexemic representations, that slows phonological encoding. Leads to postponement and restarting.

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LOCI of Stuttering (Linguistic)

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The properties of the sounds, syllables, words (particularly words) that are stuttered on…

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Evidence for Linguistic Bases

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-Significantly more stutters per utterance in utterances above a child’s MLU (Zackheim & Conture [2003])
-More preschool children stutter on function words as opposed to content words.
-Much higher percentage of CWS have disordered phonology (35%) versus CWNS (6%).

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Brown's predictors of words to be stuttered

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(1) Initial Sound: A Consonant
(2) Sentence Position: 1st 3 positionss
(3) Word Length: Five or more letters
(4) Grammatical Class: Noun, verb, adjective or adverb

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Motor Bases of Stuttering

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(1) larynx was the “site” most likely to cause instances of stuttering and
(2) temporal discoordination among speech breathing, phonation and articulation

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Temporal discoordination between respiration, phonation, and articulation (Motor)

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disruption in one component, for example, breathing, would lead to disruptions in the entirety of speech execution.

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Dynamic, non-linear influences of motor system on stuttering (Motor)

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Smith & Kelly (1997) no matter what aspect of motor control is involved with stuttering, the involvement is dynamic (changing as time and space change) and non-linear (not a simple adding of 1+1), and that for each individual, the factors are different and in different amounts…

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Emotion Based Theories (Summary)

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emotions are comprised of cognition, expression, experiences, and excitement
o Excitement = Autonomic Nervous System involvement
• Sympathetic system- spends energy
• Parasympathetic- saves energy
• Opposing forces

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Criterion for definition of stuttering

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1. Described distinct speech and language features.
2. Dependent on observable facts
3. NO mention of causation

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Emotion Based Theories (treatment implication)

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People who stutter may not be different in their arousal, but how the arousal impacts their stuttering.

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Emotion Based Theories (Phenomena of Stuttering)

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o Consistency: Increased arousal for production of certain phonemes.
o Adaptation: Decreased arousal secondary to repetition / habituation
o Spontaneous Recovery: NO

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Evidence for emotional based theories

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o Children who stutter are more sensitive or reactive to environmental changes
o More active and impulsive
o More apt to react with negative emotions
o Less adaptable, less inhibitory control
o Less effective emotion and attention regulation

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Symptom of Repressed Internal Conflict (Emotion)

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Stuttering is a psychopathy and the overt stuttering behaviors are symptomatic of a deep-seated psychological disorder.
o Aka the Repressed-Need Hypothesis
o Stuttering is seen as a neurosis, and individuals who stutter do so as a result of a represed neurotic, unconscious conflict.

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Symptom of Repressed Internal Conflict (Treatment implication)

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Little success reported by those using a psychoanalytic approach for treating stuttering.
o Important to know the historical perspective and opinions parents/patients may come across

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Symptom of Repressed Internal Conflict (Evidence against)

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o Do children who stutter grow up in a home environment that can validly be described as blatantly pathologic or unhealthy emotionally? Adams' answer was NO
o Do children who stutter grow up in a home environment that can validly be described as "emotionally unsatisfactory or conducive to maladjustment? NO
o Do children who stutter grow up in a home environment that, although not obviously pathologic, is nonetheless unique or different from the home environment of youngsters who develop normal speech? NO

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Diagnosogenic Theory (Learning based)

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The diagnosis of stuttering- that is, the decision made by someone that a child is beginning to stutter—is one of the causes of the stuttering problem, and apparently one of the most potent causes. Having labeled the child's hesitations and repetitions as "stuttering," the listener—somewhat more often the mother than the father—reacts to them as if they were all that the label implies.

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Diagnosogenic Theory (Criterion for def'n)

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o Distinctive speech & language features: YES
o Dependent on observable facts: YES?
o No mention of causation: NO

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Diagnosogenic Theory (Evidence for/against)

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o "An Experimental Study of the Effects of Evaluative Labeling on Speech Fluency" –Wendell Johnson, Mary Tudor. University of Iowa, 1939. Aka the "Monster Study."
• Fluent children were labeled as children who stutter and their teachers were given specific instructions on how to treat them. Tudor found that at the end of 3 months, all of the children showed varying degrees of speech disruptions and concern about their speech.

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Diagnosogenic Theory (Evidence for/against)

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o Reanalysis of the Tudor study by Ambrose and Yairi (2002) concluded that the study was not conducted appropriately, results were invalid and data collection was flawed. Found that labeling someone as a "stutterer" does not have a long-term influence.

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Continuity Hypothesis (Learning Based)

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Stuttering develops from the normal fluency breaks produced by young children. The tension and the fragmentation of fluency breaks increase as a result of communicative pressure. As tension and fragmentation increase, especially for part-word repetitions, the pattern becomes chronic and the child is more likely to be identified as someone who stutters.

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Continuity Hypothesis (Treatment Implication)

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Communicative partner is not as important as communicative pressure.

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Classical Conditioning (Learning Based)

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The child learns that speaking is often difficult and begins to both anticipate fluency disruptions and struggle during fluency breaks.

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Classical Conditioning (Treatment Implication)

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Once conditioned stimulus : conditioned response relationship is formed, it is only "unlearned" with inhibition.
o Inhibition can happen when a novel stimulus is introduced at the same time as the conditioned stimulus, reducing conditioned stimulus' ability to arouse.
o Inhibition can happen when a conditioned stimulus is presented repeatedly without an unconditioned stimulus, and the conditioned stimulus loses its ability to elicit the conditioned response.

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Classical Conditioning (Phenomena of stuttering)

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o Consistency: YES. CS:CR relationship is formed (phoneme:disfluency)
o Adaptation: YES. CS:CR relationship inhibited given repeated trials, resulting in reduced ability of CS (phoneme) to arouse CR (disfluency) reponse.
o Spontaneous Recovery: NO

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Operant Conditioning (Learning based)

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The fluency breaks of children are shaped by the response they elicit. The listener response to the child's fluency breaks reinforce their occurrence. The moments of disrupted fluency are then gradually shaped into greater abnormality, with associated struggle and secondary characteristics.

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Operant Conditioning (Treatment Implication)

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Accounts for the evolution of stuttering and the great variety of avoidance and escape behaviors that often develop.

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Operant Conditioning (Evidence for)

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o Brutten and Shoemaker (1967)- initial fluency breaks occur as a result of classically conditioned negative emotion being associated with the act of speaking. The negative emotion results in a disruption of the cognitive and motor sequencing of speech production. The secondary responses that help the speaker to avoid and escape from stuttering are the result of operant conditioning and soon become part of the problem.
o Flanagan, Goldiamond, and Azrin (1958, 1959) and Martin and Siegel (1966a, 1966b) found that stuttering could be reduced when immediately followed by punishing loud noises or electric shocks (OH JOY!)

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Operant Conditioning (Evidence against)

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o Williams and Martin (1974), Martin, St. Louise, Haroldson, and Hasbrouck (1975) found that stuttering behaviors are reduced in the face of punishment because the response contingent on stuttering (loud noise, electric shock, etc) serves to distract or highlight the occurrence of stuttering, allowing the speaker to change his or her behavior.

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Measures of stuttering:

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-Chronicity (will problem persist, be chronic)
-Severity (how “bad” or “significant” is the problem)-Physiological tension (muscle tensions and sensings of muscle tension)
-Psychological tension (emotion feelings of fear, avoidance, frustration or stress)-Number of iterations per repetitions
-Rate and rhythm of iterations
-Fluctuations in pitch and loudness
-Sound prolongation index

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Consistency of Stuttering

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Tendency to stutter on the same words when reading the same passage several times
-As general rule, 60-70% of stutterings occur on the same word, from Reading A of a passage to Reading B of the same passage

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Adaptation of Stuttering

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Adaptation: Tendency of stuttering to decrease with repeated readings (typically 5) of same material

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Spontaneous Recovery

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A tendency for the frequency of stuttering to increase to its former level after a delay period…
Approximately 4-5 hours after end of adaptation sequence, stuttering returns to 100% of its pre-adaptation level

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Fluency Inducing Conditions

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White noise
Altered auditory feedback
-amplifying speaker’s voice
-unison reading
-delayed feedback
-frequency altered
Metronome effect
Novel modes of speaking
Singing
Speaking in sing-song voice or monotone
Whispering, shouting
Alteration of pitch, rate, imitate foreign dialect

Response-contingent stimulation
Immediate vs. delayed punishment