Fluency Summary PDF

Need to know basic premise of pause target, word repetition target, easy onset, light contact Unit 1 The Nature of Stuttering Core Behaviors of Stuttering: 1. Repetitions: a. Types: Sounds, syllables, words. b. Considered stutters if excessive, irregular, or lacking schwa vowe...

Need to know basic premise of pause target, word repetition target, easy onset, light contact Unit 1 The Nature of Stuttering Core Behaviors of Stuttering: 1. Repetitions: a. Types: Sounds, syllables, words. b. Considered stutters if excessive, irregular, or lacking schwa vowel sounds. 2. Prolongations: a. Extended sounds (voiced/voiceless) 0.5sec-minutes b. Struggle marked by pitch/loudness changes. 3. Blocks: a. Speech “stuck” at various levels (respiratory, laryngeal, or articulatory). b. Typically appear later and grow more tense over time. Secondary Behaviors: Escape Behaviors: Attempt to end stuttering (e.g., blinking, head nodding). Avoidance Behaviors: Avoid situations or words, substitute, or circumlocute.  Starters: “my name is...”  Postponements: “um..uh..im”  Substitutions: “he’s my father’s brother”  Circumlocutions: “pass me the things you use to cut paper” Initially voluntary, evolve into habitual patterns resistant to change. Triggered by fear of negative social judgment. Onset of Stuttering Challenge in identifying onset: Relies on parental memory, which may be unreliable. Average age of onset: 2:9 (between 2 and 3.5 years old). Core behaviors at onset: Excessive repetitions; sometimes prolongations and blocks. Abrupt onset prevalence: 41-50%. Incidence & Prevalence Incidence: 5-8% (lifetime measure of how many people have stuttered). Prevalence in school-age children: 1% (current measure of those actively stuttering). Recovery without Treatment Terms: Natural Recovery and Spontaneous Recovery. Spontaneous recovery rate: 85% (Yairi & Ambrose, 2013). Most recovery occurs: Within two years of onset (Masson, 2000). Predictors of Persistence 1. Family history of stuttering. 2. Male gender. 3. Onset after age 3.5. 4. Stuttering persists over a year after onset. 5. No decreasing trend in: a. Rapid repetitions. b. Blocks and prolongations. 6. Lower than average phonological skills. Predictors of Recovery Best predictor: Strong recovery signs within 12 months of onset. Sex Ratio General: 3-4 males for every female.  Younger children (ages 2-5): Closer to 1.2 males per female. Why the ratio changes: Females tend to stutter earlier, recover earlier, and more frequently. Variability and Predictability of Stuttering Occurs on a continuum (5-20% of speech in most people who stutter). Can fluctuate in:  Frequency and severity.  Situations (e.g., home vs. school).  Language use (e.g., English vs. other languages). Historical misunderstanding: Previously believed to be psychological due to fluctuations. Anticipation, Consistency, and Adaptation Anticipation: Predicting which words or sounds one will stutter on. Consistency: Stuttering on the same words during repeated readings of a passage. Adaptation: Reduced stuttering with repeated readings (most change in first 3 readings, about 50% reduction). Language Factors Affecting Stuttering Stuttering more likely on:  Consonants over vowels.  Initial syllables over medial/final ones.  Longer, complex words (e.g., content words like nouns/verbs).  Stressed syllables or words. Fluency-Enhancing Conditions Stuttering decreases or is absent during:  Singing.  Choral speech.  Delayed auditory feedback.  Masking noise.  Relaxed environments.  Speaking alone or to pets/children.  Using rhythmic speech or dialects. Etiological Factors Constitutional Factors: Predispositions like genetics and neurological anomalies. 1. Hereditary Aspects & Genetics: Stuttering runs in families, with genetic studies showing significant predisposition. Males are more prone to persistent stuttering; females show higher recovery rates. Twin and adoption studies highlight genetic influences (genetics > env) Genome studies identify mutations (e.g., on chromosome 12) linked to neural development for speech control. 2. Congenital Factors: Physical/psychological traumas at or near birth (e.g., infectious disease in NS, head injuries, surgery, mild intelect disability, mild CP, intense fear anoxia, premature birth, or childhood diseases) may predispose stuttering. 3. Brain Structure & Function: Overactivity in the right hemisphere, high abnormal activity in cerebellum Supplementary motor area more active (related to overactivity in BG) Absence/red activity in auditory areas used to monitor own speech OP Reduced gray matter in Broca’s and auditory perception areas.  4. Other Constitutional factors: Motor processing: greater variability on motor tasks Sensory processing: difficulty with temporal info, different auditory and proprioceptive FB and processing Language: more stuttering in more complex sent (may limit resources needed to compensate for basic deficit in sensory motor control of speech) Emotion: play a role in triggering onset of stuttering and shaping individual characteristics PWS tend to have more sensitive/inhibited temperament (may respond with increased physical tension to dysfluencies) Precipitating Factors: Environmental and developmental interactions. Developmental Factors 5. Physical / Motor Skills: Variability and incoordination, particularly for complex sentences, increase persistence risk. 6. Cognitive Development: Cognitive spurts may compete with language resources. Emergence of neg attitudes and beliefs that influences tension, escape, and avoidance behaviors. 7. Social & Emotional Development: Incomplete emotional regulation and sensitivity to stress may exacerbate stuttering. Emotional arousal diverts resources from speech planning. 8. Speech & Language Development: Stuttering onset often coincides with linguistic growth outpacing motor skills. Delayed phonology increases persistence risk. Environmental Factors (precipitating/triggering factors) 9. Stressors: Competition for attention, hurried contexts, and complex language. Life events altering stability/security may precipitate stuttering. 10. Parental Influence: Overprotective or anxious reactions can exacerbate stuttering in children. 11. Life events May alter child’s stability and security (little research) eg moving, parental divorce... Psychological/Personal Characteristics 12. Temperament Some CWS are more reactive and less able to emotionally regulate But no research shows PWS are more neurotic, and we do not think temperament is the cause of their stuttering Perpetuating Factors Behavioral reinforcements perpetuating stuttering. 13. Learning Factors: Classical Conditioning: Association of stuttering with tension Operant Conditioning: Reinforcement of avoidance behaviors like fillers (e.g., "um") Main Theories 1. Cerebral Dominance Theory (Orton & Travis): a. Right hemisphere dominance or left hemisphere vulnerability may cause stuttering. b. Disorder of timing (temporal sequence) and red capacity for sensory/motor modelling c. Language production deficit (multifactorial dynamic disorder) d. Does not account for all the different types of stutters/characteristics 2. DIVA Model (Chung & Guenther):  a. Speech involves feedforward (planning) and feedback (adjusting) motor pathways. b. Adults benefit from slowing speech and using auditory feedback during therapy. c. Unrealistic for children to self-monitor; how does emotion/attention/language/brain strctr fit in? 3. Covert Repair Hypothesis (Kolk & Postma): a. Stuttering results from phonological errors in speech planning. b. Errors in articulatory plan detected and repaired before execution, leading to interruptions, restarts (repetitions), postponements (pauses, prolongations, broken words) c. If true, should treat phonology along with stuttering (many treatments do stutter first then phonology) 4. Multifactorial Dynamic Model (Smith & Kelly): a. Stuttering arises from complex interactions of motor, cognitive, linguistic, and psychosocial factors (looking for single “cause” is unhelpful) 5. Packman & Attanasio 3 factor model of moments of stuttering a. Focus on moment-to-moment impact, makes it hard to generalize b. Factors: 1) deficit in neural processing for speech; 2) triggers (linguistic complexity); 3) Modulating factors: e.g., reading aloud 6. Environmental Theories: a. Diagnosogenic (Johnson): Parents' labeling (diagnosing) of normal disfluencies leads to stuttering. b. Learned Anticipatory Struggle (Bloodstein): Repeated communication failures and pressures contribute. c. Capacities and Demands (Starkweather): Disfluencies emerge when demands exceed a child's capacities. (bucket analogy) Learning Theories Classical Conditioning:  Neutral stimuli (e.g., phone) become associated with stuttering-related anxiety.  Therapy involves desensitization to reduce fear and anxiety. Operant Conditioning:  Reinforcement shapes behaviors.  Avoidance behaviors (e.g., word substitutions, interjections) prevent stuttering but become habitual. Avoidance Conditioning:  Clients often avoid feared situations or words.  Therapy focuses on positive behaviors and desensitization. Two-Stage Model (Guitar) 1. Primary Stuttering: a. Inherited traits lead to early disfluencies like repetitions. b. Most children outgrow these disfluencies with development. 2. Secondary Stuttering: a. Emotional and conditioning responses worsen stuttering. b. Learning and environmental stressors play a role. Implications for Therapy Adjust speech and language demands appropriately. Encourage slower speaking rates and positive, assertive behaviors. Provide experiences of fluency in feared situations. Recognize emotional and learned components in therapy. Development of Stuttering 1. Normal Disfluency (1.5–6 years): a. Typical disfluencies (>10%) with no secondary behaviors or awareness. 2. Borderline Stuttering (1.5–3.5 years): a. More frequent disfluencies (12 months): Initiate treatment promptly *red flag: 10% disfluencies, 50% LTDs Key differences of school-aged assessment compared to preschool  Parent-child interaction analysis is typically excluded.  Child interviews and teacher input become more critical.  Predictor variables are less relevant (unlikely to recover spontaneously).  Focus shifts to motivation, feelings, avoidance behaviours Key Terms for Avoidance Behaviors Circumlocutions: Avoiding certain words by talking around them. Postponements: Pausing to dispel stuttering. Starters: Using filler words or sounds to "start" speech. Substitutions: Replacing difficult words with easier ones. Anti-expectancy Devices: Using accents or mannerisms to mask stuttering. Unit 3 Interventions & PSG CASLPO Practice Standards (2023 Revision) - Developmental Stuttering Role of SLPs: Identification, screening, assessment, management. Goals: Improve quality of life by reducing stuttering behaviors, addressing personal and environmental factors, and enhancing participation. B) Definition of service: Criteria for intervention o the identification of impairment in fluency or o potential development of impairment that hinders full activity /participation in communicative interactions LTDs include:  o Excessive repetitions, particularly when units of repetition are syllables/sounds (not whole words or phrases) o Prolongations of sounds o Laryngeal, articulatory, and/or respiratory blocks Signs of physical effort/tension with disfluencies (considered accessory/secondary behaviours) o Avoidance or words/situations o Fear, anticipation o Feelings of lack of control C) Scope of Practice SLPs responsible for:  the assessment of speech and language functions  the treatment and prevention of speech and language dysfunctions/ disorders  to develop, maintain, rehabilitate or augment oral motor or communicative functions. Psychological aspects may require additional preparation or referral for counseling SLPs act as resources for clients (and their families) and educate the public. D) Resource Requirements → SLPs must ensure availability of standardized assessment materials and appropriate equipment for stuttering assessment and management → SLPs must ensure that all equipment (including clinical tools, assessment and therapy materials) is functional and calibrated as required E) Risk Determination → Must sample a broad variety of speaking situations before coming to diagnosis → Must respond to referrals in a timely manner and consider all factors before considering and initiation treatment approach o should consider time of onset, types of stuttering and family history → Must strive to understand the relationship of anxiety and stuttering to inform interventions o should help patient determine factors that reduce anxiety → Must work to decrease the patient’s dependence on the clinician and the clinical environment o should focus on transfer of fluency and expanding treatment environments as much as possible F) Procedures and Competencies Screening: → Must ensure that they have the required competencies for stuttering intervention o should refer the patient to other professionals with regard to issues outside of the speech-language pathology scope of practice → Must be aware that screenings may result in false negatives (passing a patient when a disorder does exist) Assessment: → Must be based on case history information, standardized and non-standardized assessment protocols that include consideration of stuttering variability.  o Assessments must include identified areas of concerns and be patient and family centered. → Must use current and appropriate materials and approaches o should use materials and approaches that are appropriate for patient’s age, cognition, gender, education, cultural, social and linguistic background, medical and psychological status, physical and sensory abilities, hearing, vocation and that meet the requirements of the specific assessment situation. Management: → Must have a rationale for chosen interventions and have criteria to begin and end intervention → When providing direct treatment, must address reduction in stuttering severity, transfer and maintenance as part of comprehensive management plan → When providing indirect treatment, must consider the appropriate strategies to limit processes that may be maintaining stuttering behaviours → SLPs must provide education to the patient/relevant others regarding the nature of the stuttering disorder and how it related to therapy → Must provide information on services if SLP is unable to provide them Initiating Involvement of Others: → Must recommend involvement of appropriate professionals and provide information about community resources when indicated Discharge Planning → Must make recommendations for discharge based on clinical findings and make reasonable efforts to secure appropriate resources Continuing Education o Demonstrate continued acquisition of knowledge and skills necessary to provide quality assessment and management of stuttering General Aims in Stuttering Therapy All Profiles: Reduce stuttering frequency. Borderline: Facilitate fluency. Intermediate/Advanced: Address abnormality, negative feelings/thoughts, and avoidance. Possible Outcomes/Long Term Goals  Spontaneous fluency (normal disfluencies in normal speech)  Controlled fluency (application of fluency skills)  Acceptable stuttering (mild, with relaxed speaking, don’t avoid speaking) Clinical Approaches 1. Stuttering Modification (SM): a. Focus on reducing struggle and modifying stuttering (stutter more fluently) b. Phases (broadly): i. Identification: of unique factors/elements of person’s stutter ii. Desensitization: reduce speech anxiety and negative emotions iii. Variation: break up stereotypic responses; vary stuttering patterns iv. Approximation: learn new responses that reinforce fluency v. Stabilization: fluency practice, voluntary stuttering, group therapy c. Important in more advanced cases, where impossible to extinguish stutter entirely 2. Fluency Shaping (FS):  a. Establish fluent speech using techniques like easy onset and continuous voicing. b. Uses behaviour modification, where response is shaped toward fluent speech gradually c. Phases (broadly): i. Establishment: stretched syllables; full breath; easy onset; light contacts... ii. Transfer: use fluent speech in variety of settings iii. Maintenance: client becomes their own clinician Comparison: SM vs. FS Speech Modification Fluency Shaping Premise results from avoiding/struggling with Many elements of stuttering are disfluencies, fears, neg att learned Behavioural Spontaneous / controlled fluency, or Spontaneous or controlled fluency Treatment goals acceptable stuttering Affective Fears and avoidances reduced by Fears often reduced indirectly treatment goals identifying, and understanding following establishment of fluency thoughts, feelings, and attitudes Procedures Modification of stuttering; reduction Modify manner of speaking through of fear and avoidances specific techniques Structure Counseling format; less structured Highly structured Disadvantages - Slower observable fluency - Maintenance/transfer may change require more attention - More challenging for - Abnormal/artificial speaking clinician pattern - Highly prescribed (may be less motivating) Advantages - More effective in red fears - Observed behaviours change and neg attitude rapidly (may facilitate maintenance and transfer) Indicators for Approach SM: Effective for individuals avoiding speech, hiding stuttering, or with negative self- perception. FS: Suited for people who stutter openly, with no avoidance or significant self-esteem impact. Integrated Approach Combines SM and FS to cater to varied client needs. Typical for clients who stutter openly but demonstrate avoidance or negative feelings. Intervention for Early Years Indirect (2-6:11): o Suitable for children with