B4L7 Fluency & Fluency Conditions.pdf

Defining Stuttering Normal Fluency Synonymous Terms ○ Stuttering and stammering are synonymous ○ Fluency and normal speech ○ Disfluency and dysfluency ○ Primary behaviors and core behaviors/ alpha behaviors ○ Secondary behaviors and accessory behavi...

Defining Stuttering Normal Fluency Synonymous Terms ○ Stuttering and stammering are synonymous ○ Fluency and normal speech ○ Disfluency and dysfluency ○ Primary behaviors and core behaviors/ alpha behaviors ○ Secondary behaviors and accessory behaviors/coping behaviors Fluent ○ Continual and effortless flow and movement and information ○ dependent on listeners perception ○ If speech ‘flows’ easily for sound and info ○ Listeners should be able to attend to message and not how it is produced (listeners of people who stutter tend to focus more on how they produce sounds) ○ Fluency has a language and speech component Linguistic Syntax Semantic Phonological Pragmatic Speech Continuity- logical sequence of word, and syllables, presence and absence of pauses are there Rate ○ Most people talk as fast as they can ( Max and ordinary rate are similar) ○ There is a wide range of acceptable rates Effort ○ In linguistic planning Little thought on what you will say ○ In muscle movement Little muscular exertion, not much tension Little articulatory contact- usually in the OPM; may be in the chest/abdomen Little constriction of airflow ○ Little thought + Little muscular exertion = Automaticity of speech Normal Fluency Pauses ○ Conventional Pause ○ Part of a linguistic important event (junctures/ punctuation marks)  ○ Idiosyncratic Pauses- hesitation and uncertainty on the speaker’s part not due to punctuation ○ Unfilled Pause- silence longer than 250 ms- normal silent intervals ○ Filled pause- ‘fillers’, interjections Characteristics of normal fluency ○ Natural to listeners ○ With normal disfluencies ○ Faster ○ Less cognitive effort on the speaker and listener side ○ Elicits a good or neutral feeling for speakers Normal fluency should not bring about any negative attitude towards speaking ○ Prioritizes communication focus over attention to speaking mechanics Stuttering Wingate (1964) ○ Stuttering is involuntary, audible or silent, prolongations or repetitions, in the utterance of short speech elements that occur frequently and are not controllable ○ Emotional state ranges from general excitement or tension to more specific negative emotions Bloodstein (1987) ○ Stuttering is whatever is perceived as stuttering by a reliable observer who has relatively good agreement with others. Interrater reliability Perkins et al (1991) ○ stuttering i the disruption of speech experienced by the speaker as loss of control DSM V stuttering definition ○ DSM V definitions are used for research purposes ○ Frequent and marked occurrence of one (or more) of the following (listed below are the CORE behaviors of stuttering): sound and syllable repetitions; sound prolongations of consonants as well as vowels; broken words (e.g., pauses within a word); audible or silent blocking (filled or unfilled pauses in speech); circumlocutions word substitutions to avoid problematic words); words produced with an excess of physical tension monosyllabic whole-word repetitions (e.g., "I-I-I-I see him"). ○ Causes anxiety about speaking or limitations in effective communication, social participation or academic or occupational performance- individually or in any combination Dysfluencies Not equal to stuttering Typical Disfluency ○ Present for children or adult without stuttering ○ Interjections, repetitions, revisions, etc. ○ Distinct from stuttering ○ Both disfluency and stuttering interrupt communication flow ○ Stuttering should not rely only on observable behavior as it would have low reliability since we have covert behaviors of stuttering as well as feelings and attitudes towards it Typical disfluencies vs Stuttering Behaviors Typical disfluencies Whole word repetitions in both mono- and polysyllabic forms Multiple word repetition Phrase repetition Phrase revision Filled and unfilled pauses ○ Typical disfluencies occur frequently at: Before unfamiliar words Syntactic boundaries Complex and longer sentences Behavior Stuttering Disfluency Syllable repetition Frequency per word More than two Less than two Frequency per 100 word More than two Less than two Tempo Faster than normal Normal tempo Regularity irregular regular Schwa Vowel Often present Absent or rare Airflow Often interrupted Rarely interrupted Vocal Tension Often apparent Absent Prolongations Duration Longer than one second Less than one second Frequency More than 1 per 100 words Less than 1 per 100 words Regularity Uneven or interrupted Smooth  Tension Important when present Absent When voiced May show rise in pitch No pitch rise When unvoiced Interrupted airflow Airflow present Termination Sudden Gradual Gaps Within word boundaries May be present Absent Prior to speech attempt Unusually long Not marked After disfluency May be present Absent Phonation Inflections Restricted; monotone Normal Phonatory arrest May be present Absent Vocal fry May be present Usually absent Articulatory Postures Appropriateness May be inappropriate Appropriate Reaction to Stress: Type More broken words Normal disfluencies Evidence of awareness Phonemic consistency May be present Absent Frustration May be present Absent Postponements May be present Absent Eye contact May waver Normal ABCs of Stuttering Affective, behavior, and cognitive aspects Negatively developed thoughts ○ Frustration when speaking ○ Feeling of muscle tension  ○ Emotional and cognitive reactions Stuttering Iceberg ○ Overt behavior Stuttering ○ Covert behaviors Shame Guilt Isolation Denial Fear Anxiety Helplessness Affective Aspects Occurs in conjunction with stuttering Fear and anxiety ○ listener’s reaction ○ being seen as ‘poor’ communicators Guilt and Shame ○ They think they are Inherently bad ○ Because of uncontrollable factors Cognitive Aspects Thoughts or belief about stuttering, speaking, and communicating Anticipation stuttering ○ Persons with stuttering can accurately anticipate where they will be stuck/ where they will stutter ○ 96% of predictions correctly followed by stuttering ○ 95% of stuttering events occurred on anticipated words ○ Associated with loss of control over speaking & feeling stuck Avoidance ○ Anticipation leads to avoidance Feared words Feared situations Feared persons Attitude about communication ○ Even young children exhibit negative attitudes regarding communication ○ Understands that their speech is different from peers Secondary Behaviors Visible reaction accompanying speech interruptions Function to conceal or avoid stuttering Attempt to ‘minimize’ stuttering Featured in the Stuttering Severity Instrument More secondary behaviors= more severe core behaviors Can be any part of the voluntary musculature May be independent from observable interruptions Examples: eyeblinks, wrinkling of the forehead, sudden exhalation, frowning, mouth distortions, nostril quivering, and movements of the eyes, head, tongue Van Riper's Categories of Secondary Behaviors: Avoidance- feared words are avoided altogether ○ Word substitutions ○ Circumlocutions Postponement- delayed attempt of the feared word ○ Strategic pause ○ ‘You know’. ‘Well’ Starting tricks- ‘tricks’ to make the first sound easier ○ Grimacing ○ ‘Uh’ prefix Escape behavior- attempt to terminate a block ○ Head jerk, gasp ○ Interjection Anti expectancy- distracting attention from fear Stuttering Tracks By Van Riper 4 alternate paths or ‘tracks’ Which stuttering appears to develop ○ When you are on a specific track, the symptoms of the stuttering will be predictable to that track Track I ○ Stuttering is initially effortless ○ Unhurried repetitions ○ Extreme fluctuations and long remissions Period of good fluency, periods of stuttering Track II ○ Children who were late in beginning to talk; with language delay ○ Rapid, irregular syllables ○ Word repetition from the beginning Track III ○ Sudden inability to speak/complete blockage  ○ Soon followed by severe forcing and struggle, breathing abnormalities, frustration ○ Fear and avoidance Track IV ○ Sudden onset of stuttering ○ Repetition of phrases, words, syllables ○ Stutter openly with few avoidances ○ Little change in their stuttering over the years Bloodstein and Guitar Developmental Phases Bloodstein Guitar Phase I (2-6) Beginning Stuttering (3.5-6) episodic stuttering appears when part word repetitions emotional tensions repetitions predominant prolongations low concern; not much regard with frustrations, but no full awareness stuttering they exhibit pitch rise post repetition and prolongation Phase II (elementary age) Intermediate Stuttering (6-14) chronic phase full range of stuttering behaviors self concept developing, but no avoidance strategies concern regarding difficulty avoidance of situations occurs for content words: nouns, prep behaviors verbs, adjectives,and adverbs shame, embarrassment, emerging fear Phase III (8-adulthood) advanced stuttering in response to situations certain words are more difficult since Advanced Stuttering anticipation is developing no avoidance, no fear, rather irritation all of the features and impacts of stuttering (primary and secondary) Phase IV (late adol-adulthood) fearful anticipation feared sounds & words conscious of others reactions avoidance of situations Unique Presentations of Stuttering Covert stuttering Core behaviors are not really observable Affective and cognitive impacts amplified “Interiorized” stuttering Rarely appeared to block at all Anticipation and avoidance are most difficult Word Final Disfluency As discussed, Word initial dysfluency seen in TYPICAL childhood fluency disorder This disfluency is the presence of primary stuttering behaviors not in the initial position but rather they are predominant in middle and final word position Less common than typical Repetitions of the syllables or consonants ○ Middle (e.g., "Oliv-viv-viv-er") ○ End (e.g., "Oliver-er-er") Acquired Stuttering (Neurogenic) Stuttering begins in adulthood aka Late Onset Stuttering or Organic Stuttering This is quite rare No stuttering in childhood This is due to damage to the Central Nervous System (head trauma, stroke etc.) Presentations: ○ Content & function words equally likely stuttered ○ Annoyance but no annoyance ○ Primary behaviors not only in the initial position ○ Secondary behaviors are rare ○ No ‘Adaptation Effect’\Stuttering regardless of tasl (i.e. imitation, conversations, reading) Acquired Stuttering (Psychogenic) Also adult onset Absence of neurological pathology Evidences of stress or other psychological factors Cluttering Also a fluency disorder Imprecise articulation; articulation errors are present Segments are too fast overall, too irregular, or both; more affectation in prosody Other key characteristics as opposed to typical stuttering ○ Excessive ‘normal disfluencies’ ○ Excessive collapsing or deletion of syllables ○ Abnormal pauses, syllable stress or speech rhythm Comparison of Characteristics of Cluttering and Stuttering Characteristic Cluttering Stuttering Speaking rate Irregular: +300 syllables per Regular: 240 syllables per minute minute Speech articulation Slurred and/or omissions Normal Speech disfluencies Primarily other disfluencies Primarily stuttering-like disfluencies Self perception/anxiety May be unaware of disfluent Aware of disfluent speech/ no anxiety speech/anxious Expressive language Disorganized Organized Models of Stuttering Stress/Trauma Response The repressed need hypothesis ○ “Freudian: basis to fulfill erotic need ○ Not much research support ○ This has lost appeal in modern speech pathology Constitutional Abnormalities/Psychological Incoordination Models Momentary failure of physiological coordination among speech subsystems West’s theory viewed moment of stuttering s king of miniature seizure that affects the speech-motor system precipitated by emotional stress  Dysphemia ○ Inherited predisposition of persons to have speech production breakdown Perseverative Theory ○ Constitutional predisposition to motor and sensory perseveration ○ Similar to perseverative behavior for patients with aphasia Failure of Coordination ○ Stuttering as the result of failure of coordination of respiration, phonation, and articulation Brainstem Reflexes ○ Reflexes abnormally triggered when OPM movement exceed ranges of velocity, displacement, or positioning Aberrant Cerebral Dominance ○ Conflict between the cerebral cortices for control of the activity of the speech production system ○ Research has failed to show convincingly that persons who stutter are distinguished either by left-handedness or ambidexterity Basal Ganglia Circuits ○ Dysfunction in basal ganglia- thalamocortical motor circuits ○ Key role in stuttering ○ Impairing the ability of basal ganglia to regulate timing cues for speech initiation Feedback Model of Stuttering DIVA Model ○ Weakness in the feedforward system ○ Person with stuttering inappropriately dependent on auditory and somatosensory feedback ○ Leads to speech errors Failure of connectivity song brain regions ○ Presupplementary motor area, basal ganglia, and cerebellum- paces the temporal sequence in articulation Disfunction here increases risk in stuttering ○ Identified tracts which appear to be less well-developed in children Learning-based Theories Operant Conditioning ○ Stuttering is maintained by positive and negative reinforcement on complex, multiple schedule ○ Changing the form of nonfluency to struggle or silence ○ Reinforced by the termination of the aversive stimuli of nonfluency (negative reinforcement)  ○ Further cycles of change in the response may then take place due to the termination of aversive stimuli from the listener or the speaker’s own negative reactions to their speech Classical Conditioning ○ Stuttering as a disruption of fluency ○ Due to emotional arousal associated with speech and speech-related stimuli ○ Stuttering block represents not operany, but respondent behavior to emotional arousal ○ Based on typical fluent speakers, stress may produce autonomic reactions capable of disruption speech fluency Anticipatory Struggle ○ Learned belief that speaking is difficult that increase conscious interference with the way they speak ○ Hawthorne’s effect Analogous to playing sports or playing an instrument in public Diagnosogenic Theory ○ Parent feedback for child’s ‘aberrant speech’ which are just typical disfluencies, the child will then learn that their speech is aberrant therefore developing anticipatory struggle Continuity Hypothesis ○ Mild tension and fragmentation are normal speech characteristics These are magnified by communicative pressures and failures leading to stuttering behaviors ○ Can be from the child’s own ears or other listeners (as opposed to diagnosogenic (parents feedback) Stuttering as disruption to speech-language learning Covert Repair ○ Speech planning process of phonetic plans by people with stuttering are impaired ○ Normally fluent speakers can generally successfully repair defective speech plans immediately ○ When people with stuttering attempt to repair speech plan, they take many attempts before succeeding. Unsuccessful attempt result in much greater disruption of overt speech Explan ○ Connection between linguistic and motor models Issues in their connection will cause fluency failure ○ Planning and Execution Factors associated with Stuttering Family Dynamics ○ Parents have been focus of many studies ○ Family members and dynamics ○ A family environment containing plenty of pressure to speak well can exacerbate the symptoms of stuttering ○ Mothers of stutterers made more judgments of stuttering than non stutterers mothers in response to most disfluency types ○ Ss only in the case of sound prolongations and broken words Demographics ○ 1% general estimate of prevalence ○ The younger the child, the more likely is the occurrence of an identifiable episode of stuttering. Some apparently stutter during early attempts to say sentences. Around age 2.5 years (~30 months) ○ Onset: Yairi and Ambrose (2005) found that nearly 30% of their cases had onsets reported as sudden, as did 33% of cases reported by Mansson (2000) and 53% of cases reported by Buck et al. (2002) Unassisted Recovery ○ Large proportion of PWS will spontaneously recover when they reach adulthood. Estimates vary from 36% - 79% ○ More men than women stutter into adulthood ○ Girls recover from early stuttering much more often than boys