Stuttering: Core and Secondary Behaviors

• Stuttering is a disruption in the fluency of verbal expression.
• It's characterized by involuntary, audible, or silent repetitions, prolongations, or fixations within speech elements like sounds, syllables, words, or phrases.

Core Behaviors

• These behaviors are characteristics of disfluent speech itself
• They include repetitions of sounds (like t-t-t-t table, which is most common), syllables (DI-di-di-sect), and whole words including one-syllable words, but excluding words repeated for emphasis (e.g., very, very, big).
• **The bigger the chunk of language = the more acceptable it is to repeat it
• Prolongations involve airflow continuing but articulatory movement stopping.
• Fixations (blocks) involve both airflow and articulatory movement stopping.

Secondary (Accessory) Behaviors

• They are extraneous physical behaviors associated with disfluent speech.
• Escape behaviors include physiological movements the speaker thinks will help, such as eye blinks or head nods.
• Avoidance behaviors are actions taken to prevent disfluency, such as using fillers (um, uh, you know), starters ("My name is..."), substitutions/circumlocutions (talking around the problem like "my father's brother vs. uncle"), timing hand movements, or avoiding situations where stuttering is likely.
• Revisions/incomplete phrases, as well as disrhythmic phonations/altered prosody (improper stress, unusual timing) can also occur.

Autonomic Nervous System Response

• It's a visceral nervous system response.
• The ANS is responsible for the fight or flight response.
• Manifestations include: Perspiration, becoming flush or pale, palpitations, SOB

Van Riper

• Stuttering is not a major identifiable event for all developmental dysfluency
• Stuttering is caused by neurological bases

Limitations of Family History Studies

• Challenges include: Defining stuttering, lack of personal interviews, false-positives/false-negatives, family size, and varying family classes of relatives who stutter.

Twins

• Identical twins are more likely to be disfluent than fraternal twins.
• Twins are more likely to be disfluent than singletons.
• Being a twin makes one more susceptible to stuttering.

Genetic Risk Factors

• First-degree relatives with the stuttering gene are more likely to be disfluent.
• Males are more likely to be disfluent (greatest risk is male relatives of females who stutter).
• Females require more genetic "loading" for stuttering to be expressed.
• Recovery is hereditary.
• Transmission follows a single major genetic locus, best accounting for transmission of stuttering in families, which implies a small number of primary genes might be isolated.
• Primary stuttering gene with associating genes may result

Biological Genetics

• Co-inheritance is when alleles physically close on the same chromosome tend to be inherited together.
• Those with a family history of stuttering show more prolongations and blocks.
• Those with a family history may have inherited greater neuromotor instability.

Congenital Factors

• Congenital conditions are present at birth as a result of heredity or environmental influences.
• These include: Anoxia at birth, premature birth, head injury, mild CP, and mild developmental delay.

Brain Structures

• Imaging has revealed these things in children who stutter: Decreased white matter fiber tracts integrity & connectivity, delay in myelination, reduced right caudate volume & atypical leftward asymmetry, and reduced blood flow to Broca's area & posterior language areas.

Left Hemisphere Development

• It is suited for speech and language.
• If the left hemisphere development is delayed, specialized cells receive signals from the more developed right hemisphere, which can become dominant.
• Networks in the right hemisphere are less efficient for speech/language.
• The left hemisphere specializes in processing brief, rapidly changing events (fine motor control of verbal output).
• PWS may not be able to process at the SPEED required for normal speech.
• The right hemisphere is responsible for prosody.

Sensory Processing

• Areas of the auditory cortex are under-activated during stuttering.
• Central auditory processing is poorer for PWS.
• Auditory feedback – MASKING decreases frequency & severity of stuttering
• PWS has less developed sensory auditory processing system

Developmental and Environmental Factors

• Stuttering is caused by its dx

Theories

• Multifactorial Dynamic Disorder aims to determine which factors interact in stuttering and how they interact.
• Anticipatory Struggle Hypothesis (Bloodstein) suggests anticipation of imminent speaking (communication) interferes with fluency, stemming from a combination of inappropriate muscle tension and fragmentation of planned utterances.

Initial Contact with Parents

• It’s important to listen to concerns, get a sense of urgency, give them something to do while they wait, and provide reasonable reassurance.

Parent Observations/Forms

• Complete these before the initial visit.
• Examples include: Scale for rating severity of stuttering.
• Case history and early childhood behavior questionnaire.
• Videos

Decisions by the End of Assessment

• These include: No tx, watchful waiting, parent-delivered tx, clinic-based tx and referrals

Initial Clinic Interview

• Observe parent-child playing together.
• Use broader and more open interview questions.
• Observe clinician-child interaction; if the child is fluent but parents report stuttering at home, apply gentle pressure to elicit stuttering.

Formal Assessments for Preschool Child

• Stuttering Severity Instrument is based on at least two conversational speech samples (clinic & home).
• It measures duration, frequency, and secondary behaviors.
• Speaking Rate – based on speech samples

Other Assessments

• Impact of Stuttering on Preschoolers and Parents Questions
• KiddyCAT has more direct questions for the child.

Bilingual Considerations

• The challenge is distinguishing bilingual children who do and do not stutter.
• High rate of Mazes -disruptions in the forward flow of speech by the production of a string of words, initial parts, or unattached fragments of words that do not in and of themselves contribute to the message
• Lexical revision – correction of overt word choice errors (“his (frog) dog came along") Ο Grammatical revision – correction of overt grammatical errors (He was wearing the jar (in) on his head) Ο Phonological revision – correction of overt phonological errors (Squeak went the (saxalone)
• narrative task is best when eliciting language from bilingual children
• Bilingual children produced a higher percentage of stuttering-like and total disfluencies in Spanish compared to English.
• These kids ever produced - prolongations The tension on repetitions may be discriminating factor.

Differential Diagnosis

• It's helpful to check for parental concern, presence of tension/timing and tense/arrhythmic speech.
• Narrative disfluencies tend to be higher.

Onset of Stuttering

• Disfluency can progress from few, relaxed reps into - frequent stuttering, accompanied by tension, avoidance, negative feelings & beliefs
• Progressively worsening - reps turn into fixations & stopping air emotions turn from surprise to frustration to panic feeling

Typically Disfluent

• Kid who doesn't react at all just keeps going
• No secondary behaviors

Borderline Stuttering

• Disfluencies are loose and relaxed

• Child has infrequent to disfluencies

• Look for increased # of dysfluencies with qualitative differences

• Somewhat aware of their dysfluencies but isn't really reacting to them

• More than 10 dysfluencies per 100 words

• No secondary behaviors

• Iterations = rhythmic, also some do not “outgrow” borderline stuttering if the home environment does not support this.

• Limitations in expressive language skills and Low frustration tolerance for repetitions can occur.

• Developmental stressors do not diminish

Beginning Stuttering

• Repetitions become more rapid and irregular with increased tension.
• Repetitions can turn to prolongations
• Stuttering can be linked to a rise in pitch and awareness and frustration, without feeling horrible about themselves as a speaker.
• Escape behaviors and frustration begin
• A significant landmark in stuttering is when the Van Riper child is stopping the flow of air or voice at one or more places (fixations).
• Laryngeal tension is a red flag.

Intermediate Stuttering

• Emotional reaction to dysfluency
• Child begins to “fear” stuttering and begins avoidance/escape behaviors if they can't avoid them.
• Can turn to Fixations, more core behaviors, more tension, and an inability to control disfluencies.

Advanced Stuttering

• Occurs in the teenage years.
• Panic feeling that, longer and more frequent core behaviors.
• Can includes avoidance behaviors.
• Person identifies at PWS

Peer Responses to Stuttering in the Preschool Setting

• Teasing often happens because peers don't wait for the child to finish and make disparaging comments.

Start Treatment?

• If stuttering is negatively affecting social experiences of children in play, may need to consider earlier tx.
• By 9 mo after onset of stuttering, it has potential to elicit negative peer responses & limit ability to comm. in key social interactions
• Children at risk for negative social consequences of stuttering need to be - treated sooner rather than later
• Stuttering characteristics that appear to elicit negative peer responses Behaviorally complex, has long duration, and depleted utterance of meaning

Indicators related to the parent you can quantify

• High rates of speech which could includes Interruptions, Fast conversations pace, and Frequent Questions
• Things like Critical/ Directive comments and Inconsistent Listening

Quantifiable Parent Behaviors

• Advanced vocab & syntax o Simple structure at reasonable pace, NO sing-song sound

Empathy Response

• Acknowledge how someone is feeling
• Make a statement indicates understanding.
• Say nothing else until the patient responds.

Indirect Treatment

• Slow parents rate & increase pauses
• Number one thing parents screw up when they try to talk slow - robotic prosody, sing song voice, & putting breaks b/w words (as opposed to stretched)
• Basically... slow speaking rate, relaxed speech, & view videos w/ parents each session o Then meet with parents model speaking style, ask them to try it (maybe reading first) o Record model for them to remember
• Play interaction w/ child using that style

At Home

• Spend 15 minutes/day playing alone with child using new speaking style Morning = best b/c may influence rest of the day

Monitor Parents' Practice

• Make notes on Severity Rating chart and Monitor at beginning of session
• Change the family routine to create opportunities for attentive listening.

Collect data & Reinforce

• Collect data on % syllables stuttered and Reinforce parents for doing well and Give them an opportunity to talk

• "In spontaneous, unstructured talk or play, try to follow your CHILD'S LEAD. The goal is to 'march to your child's drummer', and to tune into the child at his level

• If family resistant to change or not participating in tx - may need family counseling

• Maintenance Tx likely to be effective within - 5 – 6 sessions over 1-2 months Effective maintenance based on: o Help fam view child's stuttering more objectively w/ less anxiety, guilt or panic Building fam's confidence in their own ability to implement problem solving skills They should always feel they can return to tx

Evidence to Support Indirect Tx

• Study 1 - After 6 wks, child's disfluencies were WNL (followed for 10 years, never reappeared) Biggest contributor - mother's rate reduction & more accepting comments Study 2 - Stuttering decreased when mothers slowed their speech rates

Study 3 - 29

• Reduced parents' speech rate, having special speech time, match parent language to child language, reduce negative reactions
• Strong Study (Sawyer) - Caregivers CAN be trained to slow their speech and CWS increased fluency at end of program designed to slow caregiver articulation. Some may need more direct tx if fluency does not increase enough - So, you will be changing as many environmental factors as possible & 1 on 1 child/parent time is imp., & modeling slow rate is imp. No disfluencies 10 years post therapy = best evidence

Conture's Approach

• Children's group & parents' group – meet separate & then together
• Parent group - observes part of children's tx & receives info, suggestions, opportunities to facilitate child's fluency Parents/clinician discuss child rearing issues that affect tx The Children's group - help child learn effective comm.
• Initial Phase - Groups meet x1 per wk to establish fluency and When child's stuttering in clinic is < 5% for 4 consecutive weeks, fam meets less w/ clinician to focus on transferring fluency to home, etc. - Then maintenance Children's Group 3 Rules for good communication - Listen, take turns, don't interrupt.Clinician is modeling strategies for paren and Parents Asked to observe their speaking behaviors w/ child & child's speaking behaviors then discuss w/ grou

Dismissal

• Changes in family life includes:
  • Structure w/ predictable routines as well as a Slow pace w/ transitions
  • Make child's life less busy and Consistent reasonable discipline

Yaruss Approach

• focus on the family, a typical session is composed of 3 components: Education & counseling, Communication modification and Review & re-assessment Education and Counseling2-4 sessions Includes having parents become active participants in tx.
• Educate parents, address concerns, teach parents how to respond to stuttering in a supportive manner
• The key is to educate parents on disfluency and how to address the concerns properly
• Parents also need to respond to the stuttering but be supportive and use the right tx method

First Session

• Assess stress
• If both parents present, each completes stressor inventory individually and Discuss ways to decrease impact of each stressor
• Factors potentially associated w/ childhood stuttering - Child factors, interpersonal stressors, communicative stressors
• Parents to become more knowledgeable in disfluency types b/c if disfluency types change.
• Provide resources

Steps

• If continued to stutter during parent focused components, will receive more direct tx

In moving to direct tx

If stuttering does NOT decline within 1 mo - 6 wks Parents taught to occasionally praise fluency

Steps for direct Hierarchy

• Child actively participates -“catch me”, play
• Catch me - Teaching the client awareness and identification skills Child produces intentional stutters and Child changes own real stutters Model and shape easy stutters into easy relaxed style

Palin Parent- Child Interaction

• Parent makes environmental changes and Children 7 & up.
• You can improve communication through Facilitative approach and Play based sessions, parent-child pairs
• Through video feedback – parents use to set their own targets and reinforce progress an Initial Evaluation.

Initial Evaluation

• Establish strengths/needs through use of Receptive/expressive language.
• The parent must be able to use Detailed parent interview and Summarize factors that may be contributing to stuttering & those that are helpful

Parent interaction Video Component

• Use BOTH parents w/ child once a week for 6 wks and View video to observe helpful things they're doing

• It is ultimately Parents' responsiblity - Decide target behavior to work on in daily 5 min practice sessions in Subsequent Sessions.

• Support and Principles of Tx can be created through Understanding the child's needs and is there a Profile of speech motor and linguistic strengths and needs Parents are already helping at the right time and Identify things they do that support fluency will only foster more successful tx. Overall Communicate must come from a way that matches child's fluency needs

Parents involved in homes Stuttering is discussed openly through Use age appropriate, child centered terminology Normalize the problem to reduce family's anxiety

Approach

• Goals of Tx includes:
  • Establish the foundation of parental understanding, knowledge, skill, and confidence in managing stuttering which will support and augment the child's fluency during each stage of tx
  • Reduce family's anxiety about stuttering
  • The SRS helps parents understand cause and effect relationship of what created a bad day and what created a good day

Direct approach BUT Use Praise fluency - ignore/ repeat disfluency. Can use either Group vs individual to have the Children in group progressed more quickly More direct approach BUT The Parents responded favorably to group model

Lidcombe Program

• Program has both Stage 1 and Stage 2 and typically done with a first a weekly based goal

Parental Guidelines

• Its helpful to Parental guidelines for tx Recommended parenting book with the program is very helpful and It provides specific feedback

School-Age Children

• Try to aviod Stuttering by using these steps

Fluency Shaping

• Ideally stuttering is avoided
• Principles for tx:
  • Relaxed breath, Easy Phonatory onset and Coarticulation
  • Light Articulatory Contacts and it includes a Relaxed diaphragmatic breathing, Reduced rate and prolonged syllables initially, Easy onsets and offsets and Light articulatory contacts

Stuttering Modification

• Is the process of managing moments of stuttering that cannot be avoided Is implemented by:
• Model to ease the stutter
  • In the moment of stutter speaker must voluntarily changes it during this part and Can move forward with speech as well

Fluency Goals

• Really matters when talking to adults about how fluent they need to be Can use: Controlled and or voluntary stuttering during the process of speech It focuses on using a goal and accepting stuttering at the right place through tx

Tx Plan and SuperFluency Plan

• Steps include:
  • Exploring stuttering and Making stuttering easy with Learning superfluency
  • Then after the pt gets familiar with those steps there ready too Using superfluency Guitar has the "approach" and with Goals that can be achieved with the fluency shaping and stuttering modification through Specific fluency skills.

The specifics

For flexibility The key focus is to only have the syllables in which stuttering is expected are slowed at almost every cost. When trying to tx: PWS you almost never "race care analogy" it by letting Plosives turn into fricatives and Pausing. Focus on helping prepare to say feared word more slowly & Can use the time to reduce muscle tension and allow the brain to stay at a processing speed that is more comfortable Easy Onsets - best way to avoid laryngeal fixations and Light Articulatory Contacts - best way to avoid articulatory fixations

The specifics to bypass auditory

Show the client will be be Illustrate - catch soap bubbled, pickup sticks, Proprioception and client is focuses on feeling the movements of articulators as they say something, Focus on replacing through the Replacing Stuttering with Superfluency - easy to difficult, unfeared to feared

Replace fluently

• It's not desensitization if role playing isn't occurring, its almost always through
• It helps bring more realistic situations and almost always gets more difficult, its better if you Bring in other children and adults
• All ways to increase fluency with the pt reduces fear and avoidance by Talking about other fears they've overcome with letting Talk about how other get over fears

Reducing fears

• Talk about what the pt is fearful of
• Let child know that being fearful causes him to tense up and stutter
• Steps to reduce fears includes - Be okay with having some fear, Study words or situations so they can learn about them, Practice superfluency over and over and Get reward for trying something despite fear, even if not completely fluent

Coping with Teasing & talking

If able to, it would also help to learn acknowledge it by saying "Yeah I stutter, so", be very clear in the situation by Being open about stuttering and Decreases fear, embarrassment, and physical tension. Giving oral report – “My report is about PPJ, I might stuttering, don't let it bother you, im working on it) It helps even more through Talking by Sharing info when ready!

Maintaining

• Be prepared in what the pt needs and Provide a way to Gradually phase out, Obtain speech samples and it could even mean Interviewing parents. Always want to provide a safety net by making sure the pt needs and knows he can always return back Eliminating Teasing at home and Clinician may want to talk with sibling who teases. They also shouldn't want to react while dealing with the pt as that has a negative.

Class

• Have the pt try to explain tx program and teachers role with facilitating teaching talking with student about his stuttering is much more ethical
• Have the class try to Help student and teacher work out child's participation and Help teacher eliminate teasing
• Help the pt get a fair place in when called and order in which to speak in from of the class, informing the students about stuttering

Lidcombe for School-Age

• The procedure is "the same as before with parent training," but there's much more the pt has to deal with This will require some additional Contingencies as well as the need to Systematically decrease

the school may not be as helpful

There for "Finding the right for the structures can"

School is too much

Fluency Rules Program

• Is almost exclusively for patients while on paper with school and will require more Pt will be:
• Speaking slowly with 1 word at time.
• The tx might use for speech therapy would include, DAF or DAW
• What to AVOID The way that has a long term effect is if you try to increase the length and complexity of the phrase This is because its for tx

Comprehensive and Smooth

• A comprehensive approach will Change timing to enhance fluency (slower speech and pausing), and to help with the issue focus on Change Change timing and tension to enhance fluency (east starts)
• The point if for to only enhance in which is why change tension to reduce the severity of stuttering (exploration and pseudostuttering)

Minimizing Issues/ Reactions

• Do a combination of Disentization to help see if you can change "Cognitive restructuring"

The main environmental Issues that is always at effect Parent, the teacher, and piers But always work from the front. That can only be achieved with some support and a structured hierarchy

Helping the Pt while minimizing and handling reactions Show the Pt has a "Bigger challenges for parents" AND the doctor is Believing some things will also change if the Pt is trying too hard. That will only hinder the process while in the long room

Final Overall thoughts and plans

• There needs to be an Overall Assessment of Speaker's Experience which allows a look at individual stuttering QOL and almost always means some tx must be changed Some times using general plans has to be changed a bunch Remember there "General perspective" of that is at the right spot and be the biggest component that is right there
• Help with consideration, psychological factors and freedom Resilience is a dynamic process in which individuals adjust and cope in an adaptive manner when confronted with significant and threatening adversity and Ability to maintain a reasonable QOL when dealing with stresses and strains of

There are always barriers in the long run

• Is a choice that has a big say. Freedom is not easy and is almost exclusively done on a pt with a huge history there

For helping the pt there are just some things the doctor as to do

• A Camperdown that doesn't include naturalness is a no go

And for the doctor there is more pressure. Not only is there Proplonged Speech but is has to has "NAT scores daily" What that long line means is pt almost can not express the emotions of being an artist.

• All tx helps with group has some help.

• The doctor has to have the tools and some techniques to go forward.

Explore stuttering, a fluency disorder marked by repetitions, prolongations, and fixations in speech. Understand the differences between core behaviors (disfluent speech characteristics) and secondary behaviors (physical movements associated with disfluency). Learn about escape behaviors and their role in stuttering.