Fluency Notes PDF

Fluency Disorders: Basic Information & Epidemiology Introduction to fluency disorders Fluency Disorders Fluency is the effortless flow of speech Normal fluency – Ease and ongoing flow of speech musculature and speech sounds – Suitable speech rate: across and within words – Continuity: across and...

Fluency Disorders: Basic Information & Epidemiology Introduction to fluency disorders Fluency Disorders Fluency is the effortless flow of speech Normal fluency – Ease and ongoing flow of speech musculature and speech sounds – Suitable speech rate: across and within words – Continuity: across and within words – Tension effort: Appropriate regulation of force Types of Fluency Disorders Stuttering Developmental / Neurogenic / Psychogenic Cluttering 雜亂 Unusual breathing patterns Word-final disfluency Language disorder Terminology Referring to Those who Stutter Direct label – Stutterer – Discrimination/negative connotation; medicalisation – Recent view as identity‐first language Person-first label – Person who stutters (PWS) / Child who stutters (CWS) / Adult who stutters (AWS) – Avoids negative connotation e.g. belittle, derogate, stigma – Limitations: Does not necessarily alters negative perceptions Expression / grammatical issues e.g. “the study were conducted on people who stuttered” Neurological Diversity Movement Eg. ASD→ isnt disorder, different brain structure Speech Contains Stuttering Stuttering / Stammering Disfluency – dis = “not” or “unusual” – Does not necessarily mean stuttering or disorder Dysfluency – dys = “abnormal” – Does not necessarily mean stuttering Nonfluency – Does not necessarily mean stuttering or disorder Stuttering-like disfluencies Speech Contains No Stuttering No stuttering – Simple and causal form Stutter-free speech – Formal form Fluent speech – Often refer to as speech with no stuttering Issues: – What about normal disfluencies in the above situations? Definition of Stuttering No satisfactory definition Three approaches: 1. Objective / Symptomatic definition 2. Perceptual definition 3. Internal definition Objective / Symptomatic definition World Health Organisation International Classification of Diseases (ICD-11) Developmental speech fluency disorder is characterized by persistent and frequent or pervasive disruption of the rhythmic flow of speech that arises during the developmental period and is outside the limits of normal variation expected for age and level of intellectual functioning and results in reduced intelligibility and significantly affects communication. It can involve repetitions of sounds, syllables or words, prolongations, word breaks, blockage of production, excessive use of interjections, and rapid short bursts of speech. 1. (a) Disruption in the fluency of verbal expression, which is (b) characterized by involuntary, audible or silent, repetitions or prolongations in the utterance of short speech elements, namely: sounds, syllables, and words of one syllable. These disruptions (c) usually occur frequently or are marked in character and (d) are not readily controllable. 2. Sometimes the disruptions are (e) accompanied by accessory activities involving the speech apparatus, related or unrelated body structures, or stereotyped speech utterances. These activities give the appearance of being speech-related struggle. 3. Also, there are not infrequently (f) indications or report of the presence of an emotional stats, ranging from a general condition of "excitement" or "tension" to more specific emotions of a negative nature such as fear, embarrassment, irritation, or the like. (g) The immediate source of stuttering is some incoordination expressed in the peripheral speech mechanism; the ultimate cause is presently unknown and may be complex or compound. Describes the features of stuttering Seven features grouped under three parts – First part: Core features – Second and third part: Accessory features Issue – Differential diagnosis between stuttering behaviours and normal disfluency – Covert stuttering is overlooked overt stuttering is sth u can see Perceptual Definition Stuttering is perceived by a reliable observer Relies heavily on “expert” skills Simple procedure Clinically efficient Issues – No clear procedure – ReliabilityTraining and external rater Internal Definition “... temporary overt or covert loss of control of the ability to move forward fluently in the execution of linguistically formulated speech” Only the person who stutter (PWS) truly knows whether he/she is experiencing stuttering Observers cannot objectively identify the involuntary disruption of speech Stuttering involves a constellation of experiences beyond speech behaviours: – Sensation of anticipation, stuck, loss control – Affective and emotional reactions; behaviour reactions; cognitive reactions – Impact in real‐world/life Issues – Describes the nature rather than behaviours of stuttering – Differential diagnosis between stuttering and normal disfluency – Clinical threat – Ability to and reliably identify the moments of stuttering (short vs later times) Which definition to operate on? Integrated Definition is preferred. 1. Internal definition (Optional) 2. Perceptual definition (Experts can help, you may ask other expert to help) 3. Objective definition (Collecting supportive evidences i.e. different symptoms by professional observation) Possible consideratiopn - Experience and skills of clinician - Purpose of visits / diagnosis（E.g. 家長：我唔知距係唔係 / 我覺得距一直都係） - Assessment scheme / tool used - Age of client Features of Stuttering 1. Stuttering Taxonomies 2. Johnson’s disfluency categories 3. Clonic and tonic 4. Primary and secondary stuttering / Core and secondary behaviours 5. Stuttering-like disfluencies (SLD) 6. Lidcombe behavioural data language (LBDL) Core vs secondary Johnson’s Disfluency Categories Eight categories – Word repetition – Sound/syllable repetition – Phrase repetition – Interjection – Revision – Incomplete phrase – Broken word – Prolongation Applicable to stuttering and non-stuttering children Clonic and Tonic Based on medical terminology of muscle activity Kinematic status of speech mechanism in stuttering Clonic stuttering – Repetitive movements Tonic stuttering – Static靜止的 speech organs Primary (Core) and Secondary Stuttering Primary stuttering / Core Behaviours – Simple disturbance of speech – Mostly at the beginning of the sentence – Repetitions, prolongations and blocks Secondary stuttering / Secondary Behaviours – Conscious of stuttering, attempts to control or conceal – Struggling behaviours involving mouth, head, limbs, respiration, use of fillers etc – Avoidance e.g. changing words Stuttering-Like Disfluencies (SLD) Stuttering-like disfluencies (SLD) – Part‐word repetition e.g. 今‐今日, wu‐wu‐玩具 – Single‐syllable word repetition e.g. 我我想, 飲飲飲水 – Disrhythmic phonation: Prolongations (e.g. f ‐ 飛機) Blocks (e.g....波) Broken words (e.g.火...車) Other disfluencies (OD) – Interjection e.g. um, er – Revision / abandoned utterances e.g. 妹妹倒瀉...打瀉杯水, 我想... 不如去公園玩啦 – Multisyllable / phrase repetition e.g. 佢地佢地好曳, 因為因為 Lidcombe Behavioral Data Language Describes the moment of stuttering Describes both audible and visible features of stuttering Validity and reliability tested empirically Applicable to Cantonese and Mandarin Lidcombe Behavioral Data Language (LBDL) 1. Repeated Movements - Syllable Repetition - Incomplete Syllable Repetition - Multisyllabic Unit Repetition 2. Fixed Postures - With Audible Airflow - Without Audible Airflow 3. Superfluous Behaviours多餘 - Verbal - Nonverbal LBDL: Repeated Movements Repeated movements of the speech mechanism Syllable repetition – Entire syllable – Perceptual syllable boundary rather than morphological – E.g. “bay‐bay‐baby is crying“ or “我我我想食蛋糕” Incomplete syllable repetition – Part of a syllable – Vowel of a syllable or just consonant – E.g. “t‐t‐Thomas the tank” or “m‐m‐唔該” Multisyllabic unit repetition – More than one syllable – Multisyllabic word repetition e.g. “butter ‐ butter ‐ butter on toast” or “你哋‐你哋‐你哋去邊?” – Group of words in an utterance e.g. “put it‐ put it‐ put it there“ or “我唔‐我唔‐我唔想要” – A number of syllables in a multisyllabic word e.g. “dino‐ dino‐ dinosaur” or “圖書‐圖書‐圖書館閂咗” LBDL: Fixed Postures Attempts to speak but the phonatory structures stopped Fixed postures with audible airflow – May observe arrest – Prolonged phonation Fixed postures without audible airflow – May only observe arrest – No perceive sounds LBDL: Superfluous Behaviours Verbal superfluous behaviours – Verbal behaviours also appear in normal disfluencies – Interjection, incomplete phrases and revisions Nonverbal superfluous behaviours – Visible e.g. facial, head and/or torso movement – Audible nonverbal (extraneous phonation) e.g. inspiratory phonation, grunts, inappropriate noises and sudden fluctuations in pitch and loudness Co-occurring Stuttering Behaviours Stutters can co-occur Several stuttering behaviours can all happen in one stuttering moment E.g. Syllable repetition and fixed postures with audible airflow “pack- pack- paaaa- packet of chips” “呢- 呢- niiii- 呢架係紅色車” Which one should I use? - Descriptive Power (是否需要咁comprehensive分析？到底要分到幾細？) - Consistent and precise terminology - Reliability - Facilitates communication - Clinically meaningful - Knowledge / Skills - Training Stages of Stuttering Early and Advanced Stuttering No consensus on age cut-off Based on a number of features: – Age – Dysfluency types – Frequency – Psychosocial responses – Loci 基因 of stuttering Barry Guitar’s Approach Borderline: 1.5 – 3.5 years old Beginning: 3.5 – 6 years old Intermediate: 6 – 13 years old Advanced: 14 years old and above Stuttering & Normal Disfluency Normal Disfluency (it happens to everyone) Difficult to differentiate between normal disfluency and stuttering Degree of disfluencies varies between and within child Maybe associated with language development, motor learning, other developmental, environmental or interpersonal influences Differential diagnosis: – Frequency – Types of stuttering – Speed of repetition – Number of repetitions – Distribution/cluster of stuttering The Iowa Study (data from fluent children) – Frequency of behaviours Less disfluencies (Approximately 7 per 100 words; 6 per 100 syllables) Less units of repetitions (1 or 2 units) – Type of behaviours Interjections, revisions and easy whole word repetitions No secondary behaviours – As the children grow: Interjections and part‐word repetitions decreases Revisions and phrase repetitions increases – Rarely aware about their disfluencies The Illinois Study (data from fluent children) – Stuttering‐like disfluencies – Frequency of behaviours Less SLD (Approximately 1.5 per 100 words) Less units of repetition (Approximately 1 unit) – Types of behaviours Interjection, revision/abandoned utterances, multisyllable/phrase repetition – Lower proportion of SLD to other disfluencies Children who stutter (CWS): Approximately 66% Fluent children: Approximately 28% Unambiguous 明確 Stuttering Moments Refer to moments during speech that are clearly stuttering rather than normal disfluency, as judge by the observer A particularly useful concept in clinical settings: – With young children – Parent training Differential diagnosis: Stuttering or normal disfluencies? - Stuttering definition (E.g. Perceptual / SLD - Stuttering like disfluencies, etc.) - Who and when would treatment be offered to? (做完之後決定是否需要比Treatment) Follow-up Question: What about normal disfluencies in people who stutter (PWS)? Phenomena 現象 of Stuttering - Variability - Anticipation - Consistency - Adjacency鄰接 - Adaptation - Fluency including conditions Variability Vary situation to situation and from day to day in: – Frequency – Intensity – Duration Greater variability in children Associated factors: – Audience / conversation partner: size and type – Linguistic and paralinguistic factors – Speaking situations – Emotional stress and anxiety level – Stuttering specific phenomena e.g. adaptation, fluency‐inducing conditions Anticipation Ability to predict what sounds or words will be stuttered on Prospective anticipation – Predicts difficult words that stuttering will occur Immediate anticipation – Sensation of upcoming stuttering during speech Consistency Tendency to stutter on the same words when reading a passage repeatedly Possible explanation: – Anxiety about specific words Adjacency When stuttered words are removed from a passage, stuttering tends to occur on words located near the removed words when the passage is read again Possible explanation: – Anxiety about specific words Adaptation Stuttering gradually reduces when reading the same passage repeatedly (5-6 reads) Mechanism unknown Possible explanations: – Subtle speech motor change over successive readings – Reduce anxiety with repeat readings – Motor learning Fluency Inducing Conditions 誘導 Conditions where PWS can produce more or completely fluent speech Changes the normal way of speaking – Prolonged / DAF speech – Singing – Choral reading – Slowing down – Syllable‐timed speech – Adaptation – Masking – Whispering – Speaking in different dialect / accent – Speaking alone or to an animal or infant How could I make use of these? Possible Considerations 1. Making diagnosis 2. Basis for treatment 3. Diagnosis treatment 4. Research Epidemiology of Stuttering Onset Mean age of onset: 30 – 36 months Yairi & Ambrose (2005) – Longitudinal study of 163 CWS – 24‐35 months: 60% – 42 months: 85% – 48 months: 95% Reilly et al (2009; 2013) – Longitudinal study of 1619 children (137 CWS) – Median age: 29.9 months – String three or more words together: 97.1% – Onset slowing after 3;6 years Shimada et al (2018) – Longitudinal study of 2274 children at 3 years of age – Around 24 months: 18.8% – 25‐30 months: 21.9% – 31‐36 months: 59.4% – No follow‐up after 4 years of age Types of onset – Sudden: develop within 1 week – Gradual: develop over 1 week – 33‐53% with sudden onset Patterns at onset – Repetition type stuttering Prevalence Occurrence or rate of diseases at one time-point Preschool-age children – Range from 1.4% to 5.6% – Majority lacks direct assessment of the children School-age children to young adults – 6‐10 year‐old: 0.33 – 1.44% – 11–20 year‐old: 0.47 – 1.15% General population – 0.72% Incidence Occurrence or rate of disease over a period of time Danish study – All children born in 1990 to 1991 on the island of Bornholm – Nine‐year follow‐up – By age of 3: 4.99% – Cumulative incidence by ninth year: 5.19% Australian study – 1,619 children recruited from age 2 onwards in Melbourne – 137 children diagnosed with stuttering – By age 3=8.5%;by age 4=11.2% Japanese study I – 2274 children at 3 years of age between 2009‐2012 – 94.4% of total children in the city in Hokkaido – 32 children diagnosed with stuttering – At age of 3: 1.41% Japanese study II – 2055 children at 3 years of age – Parent survey – At 36 months: 8.9% – Lack direct assessment Gender Ratio (biological reasons) Near onset – Boys : Girls – 1.58: 1 to 2.1:1 Older – Boys : Girls – 2.8:1 to 7.5:1 Why? Risk factors for Stuttering Danish study – Family history (67%) – No regression; genetic pool Australian study – Male (OR = 1.51) – Twin (OR = 3.26) – Mother’s education level (High‐school: OR = 0.99; Degree: OR = 1.75) – Advanced communication skills at age 2 (OR = 1.22 per 15 unit) – 3.3% variance explained in statistical model Japanese study – Family history of stuttering (OR = 3.26) – Concern about child’s development (OR = 1.90) – Child’s diseases or disabilities (OR = 2.45) – 5.3% variance explained in statistical model Natural Recovery More common in younger children and closer to onset 65% - 85.0% of children Some data: – 70% at 4 years post onset; 71.4% by age 5; 65‐72% by age 7; 85% by age 9 – 50% chance before teenage years – 6.3% within first year; 65% at age 7 (Reilly et al 2013; Kefalianos et al 2017) Predictive factors of natural recovery – Female gender – Negative family history of stuttering – Younger age of onset – Stronger language skills (especially in female) – No co‐occurring speech sound disorders – Lower or consistent level of stuttering‐like disfluencies (?lower stuttering severity) – Decline in stuttering severity trend within first 12 months of onset Class 2 Factors Associated with Stuttering & Causal Theory of Stuttering The prologue of the day... No definite known causes of stuttering → many theories and models Research shows a number of factors associated with stuttering How does knowing the cause of stuttering help us clinically? Do I really need to care about these factors to manage stuttering? Relationship between Cause and Factors Factors Associated with Stuttering Factors Associated with Stuttering 1. Biological 2. Language 3. Cognitive 4. Speech-Motor 5. Environmental 6. Psychological Biological Factors FACTORS ASSOCIATED WITH STUTTERING Biological: Genetics Strong genetic predisposition Family incidence method – Approximately 30‐71% with family history of stuttering Twin studies – High heritability of 0.60 to 0.85, with 1 equals to perfect concordance rate – Limitations: Twins more susceptible to some disorders No perfect concordance rate environmental factors Family aggregation method – Utilizes probands detailed predigrees – More prevalent among first‐degree relatives, up to 15% – Strong genetic bias to males – Relatives of females who stutter are at higher risk Biological genetics – To identify the DNA materials to locate the stuttering gene – No single gene serve as major cause, could be a combination of chromosomes – Related to Chromosome 2, 3, 5, 7, 9, 12, 13, 14, 15, 16, 18, 20 and 21 – Linked to rare variants of lysosomal targeting pathways genes (GNPTAB, GNPTG, NAGPA, AP4E1) – Genes link with neurological processes for speech production Adoption study – Biological, environmental, adoption and low risk – Positive speech, language or fluency diagnosis: 25% of children with genetic risk 9% of children with no genetic risk – Positive history of disorder is the strongest predictor of children’s status – Provide evidence that stuttering is not acquired from listening to the parents who stutter Biological: Neurology Brain activity – Reduced excitability in motor areas prior to speech production – Atypical activation in left inferior frontal gyrus and right auditory regions – Increase right hemisphere activation; decrease temporal lobe activity; unusual cerebellar activation – Stronger frontal lobe activation; increase activation in cuneus and right lobule IV cerebellum – Positive correlation of activity in basal ganglia and stuttering severity – Abnormal functioning of supplementary motor area (SMA) Structural anomalies – Many stuttering related brain regions: frontal lobe, parietal and temporal perisylvian regions, subcortical structure, limbic region – Increase size of right planum temporale (superior temporal gyrus) Symmetrical white and grey matter volume rather than leftward bias Increase number of gyri and gyri variability – Gray matter volume differences in left inferior frontal gyrus and the connections to supplementary motor area, temporal regions and right inferior frontal gyrus – White matter abnormality Contradicting / Unclear findings – Imaging technique and task differences – Age – Treatment experience / plasticity Language Factors Language: Linguistic Positions – Initial sound of words – First word of an utterance – Rare at end of word Word class – Content vs function (Have little or no semantic content e.g. articles, demonstratives, quantifiers, prepositions, conjunctions etc.) words – More on content words for adults – More on function words for children Word frequency – More on low frequency and less familiar words Linguistic stress – Stressed syllables – Variability of linguistic stress Utterance complexity – ↑ syntactic complexity – ↑ utterance length Phonetic complexity – Conflicting findings Speech rate – Negative correlation between speech rate and stuttering frequency – Longer utterances containing stuttering are slower Lexical tones – Mandarin: T3 and T4, under conflicting situations – Cantonese: No differences (at syllable level) Language: Language Skills No strong evidence to support the link between stuttering and language No convincing evidence of language deficit/disorder in CWS but maybe language skill differences Advanced language skills contribute to the onset of stuttering Recent study: Children with history of stuttering demonstrated higher early communication and language scores compared to fluent peers Concomitant伴隨 disorder Cognitive Factors Cognitive Skills & Stuttering Area being investigated: – Executive function: working memory, inhibition, cognitive flexibility – Attention Inconsistent findings Differences, if exist, are subtle and clinically insignificant Working memory: – Weaker in verbal short‐term memory – Parents reported less proficient working memory Inhibition – Differences between parent and behavioral measures Flexibility – Parents reported less flexibility Attention – Differences between parent and behavioral measures – Lower accuracy on attentional shifting task – Less efficient in disengaging and slow attention shifting Speech-Motor Factors Speech-Motor Control & Stuttering Speech-motor control: – Jaw displacement / movement tracking during speech / electromyography – More variability in speech motor control in both AWS and CWS – Poor speech motor control with increased sentence length – Differences in motor coordination variability between persistent and recovered group Speech rate – Speech rate / articulation rate – Negative correlation between “speech” rate and stuttering frequency – Longer utterances containing stuttering are slower Environmental Factors Environmental Factors & Stuttering Parents – Attitudes towards child’s speech e.g. demanding, anxious Communication – Speaking situations – Demands for communication skills – Communication style e.g. questioning, parent’s speech rate No significant difference between assertiveness, responsiveness use of recast in parents with CWS and CWNS Parents of CWS do not interrupt CWS speech as much as parents of CWNS – Language complexity No significant differences in linguistic demands posed by parents of CWS and CWNS Life events – Significant family events e.g. moving, pass away, marriage issues – Change of routine e.g. school holiday, traveling, new school year – Discipline of child Psychological Factors Psychological Factor: Temperament Temperament氣質 is how a person responds to and interacts with the environment Nine dimensions – (1) Activity level; (2) Rhythmicity; (3) Adaptability; (4) Attention span/persistence; (5) Threshold of responsiveness; (6) intensity of reaction; (7) Quality of mood; (8) Distractibility; (9) Approach Little evidence of association between temperament and stuttering – 6/131 statistical tests showed significant results (chance level) – Persistent CWS are judged to be more negative in temperament compared to recovered CWS So? What do they mean clinically? 1. Understanding prognosis 2. Understanding cause 3. Holistic management 4. As therapy targets 5. Information counseling Causal Theories and Models of Stuttering Historical View of Stuttering Diagnosogenic 診斷性 Theory Labeling stuttering = diagnosis Parents labeling of normal dysfluencies Parental pressure worsens stuttering Evaluating Theories and Models More controversies... No known cause of stuttering No satisfactory theories and models No consensus Appears multifactorial Criteria for a Strong Theory or Model Current Theories and Models 1. Demand and Capacity Model Demand for fluency > Capacity of production Neither ”demands” nor “capacities” have to be abnormal, deviant or disordered 異常或無序 Four main domains: – Speech motor control – Language development – Social and emotional functioning – Cognitive development Challenges can come from within the child, external environment or both – Time – Environmental pressure – Parental demands – Excitement and anxiety – Use of complex language Children’s capacities increase as they grow and develop; simultaneously, the demands increase as children are expected to be more mature Mismatch of Demands and Capacities 2. Sensory-Motor Modelling Theory Deficit in neural processing resources of the auditory-motor pathway in speech production Necessary but not sufficient to cause stuttering Could compensate with sufficient resources e.g. intelligence Demands of speech act Other factors impact on stuttering severity 3. Covert-Repair Hypothesis Stuttering is a response to excessive number of errors / flaws in a person’s phonetic plan PWS have slower phonological development and encoding PWS make excessive errors compared to PWNS Not related to impaired self-monitoring, error-detection or different types of phonetic planning errors Stuttering behaviours are ”attempts” to repair these errors 4. Anticipatory Struggle Hypothesis 預期 Cognitive disorder Stuttering is a learned behaviour The child beliefs that speaking is difficult yet important This belief causes struggle, tension and fragmentation of speech motor activity → result in stuttering Develop a self-concept of a poor-speaker → anticipation of difficulty on words or situations Sources of belief: – History of language and speech difficulties; – Experience in speech and language therapy; – Pressure from excessive praise by parents during early speech and language development; – Parent’s high expectations of speech – Expecting child to have high and perfectionistic standard for speech Incipient stuttering初期口吃 vs developed stuttering – Genetic factors 5. Interhemispheric Interference Model半球間幹擾模型 Two factors: (1) Inefficiency in supplementary motor area (SMA) function (2) Labile or equal system of hemispheric activation SMA – Fragile and susceptible to ongoing neural activity Hemispheric Activation – Overflow of information from the right to left hemisphere – Lack of left hemispheric activation bias 6. Extended GODIVA Model The extended gradient order directions into velocities of articulators (GODIVA) Computational model of speech production based on brain research of the neural aberration Two hypotheses: – WMF GODIVA White fibers associated with speech production are impaired Error in neural transmission – DA GODIVA Elevated levels of dopamine Delayed in producing the speech sound map of the stuttered syllable 7. EX PLAN Model EX: Execution or motor level of speech PLAN: Linguistic level of speech planning EX and PLAN are two independent systems Fluency failures occur when linguistic plans are sent too slowly to the motor system Mismatch between timing of planning or timing of execution Stuttering can result from: – Language processing deficit (PLAN) – Motor timing deficit (EX) Explains why stuttering is more on content words and phonetically complex word 8. P&A 3-Factor Model Multifactorial explanation of stuttering Explains the causes of individual moments of stuttering All causal factors must be operating at the moments of stuttering Three factors: – Deficit in neural processing – Trigger of stuttering: variability in linguistic stress; linguistic complexity – Modulating factors: determines triggering threshold 臨界點– physiological arousal and cognitive demands You’ve been researching on it for so long and still don’t know? Now, WHAT do I tell my clients? What we know is tru -brain factors Genetic factors Language factors All appear mutifactorial Assessment and Outcome Measures of Stuttering Introduction to Assessment Goals of the Assessment Describe stuttering behaviours Understand needs and wants in therapy Understand the factors and situations that affects fluency Explore need for further referral e.g. clinical psychologist, counsellor etc Determine and possibly trial the most effective therapy Evaluate prognosis and establish expectations of intervention, including outcomes, roles and responsibilities etc Comprehensive Fluency Assessment Guidelines 1. Case history with the person and significant others 2. Speech fluency analysis: frequency, severity, types and duration 3. Other speech related measures: speech rate, speech intelligibility 4. Awareness of speech disfluency 5. Stimulability testing 6. Communication effectiveness 7. Psychosocial aspect and impact of stuttering 8. Concerns and expectations of intervention 9. Other speech and language concerns Assessment Domains to be Discussed 1. Case history 2. Speech and language skills 3. Fluency – Frequency – Severity 4. – Types/Behaviours 5. Fluency-related QoL; General health-related QoL 6. Impact of stuttering e.g. psychosocial, cognitive-aspect of stuttering Exacerbating / interacting factors e.g. social, environmental Case History Case History Domains 1. Purpose of visit 2. Medical History 3. Developmental History 4. Social History 5. Speech and Language History 6. Bilingual History 7. Stuttering History 8. Description of Stuttering 9. Impact of Stuttering on Life 10. Expectations Purpose of Visit Why are they coming to see you? Particulars & Social History Gender/Age Occupation Family Social relationships Personality Interests / Hobbies Medical History Birth conditions Diseases, injuries, allergies Operations Medications Neurological issues General health (URTI, ear infections) Developmental milestones Speech and Language Speech or language ability Previous speech therapy? – Previous Treatment?Types?Duration?By who? – Did it Work?Why Or Why not? Bilingual History Number of languages Age of acquisition for each language Length and type of exposure to each language Language proficiency / Language dominance Stuttering History Stuttering onset Situations surrounding start of stuttering Type of stutters Severity at onset Family history of stuttering and natural recovery Development of & Current Stuttering Changes in stuttering since onset Continuous or episodic stuttering Type of stutters now Severity perceived by the client Situations where stuttering is more or less Hierarchy of Difficult Situations List of speaking situations which client finds difficult: – Speaking to girls/boys/dates – Interviews – Speaking to teachers/authorities – Saying Own name – Ordering Food Client ranks situations from easiest to hardest – Task10=easiest – Task1=hardest Impact of Stuttering History of bullying or teasing Avoidance of situations How is client affected by stuttering? How is client coping at home/work/school? How does client feel? Knowledge of Stuttering Perceived cause and triggers of stuttering Client Expectations Why speech therapy now? What would they like to achieve? Fluency or better communication? Realistic expectation? Expectation of the assessment and at the end of treatment Important Issues Get to know client as individual Build relationship with client Understand their point of view Develop skills and sensitivities in working with clients from other cultures Interview Considerations Who is/are your client(s)? – Parent – Child Client’s age – Preschooler – Schoolage – Adolescent – Adult Use appropriate language, ask relevant questions Equipment and Materials Equipment and Software Equipment – Speech fluency rating machine http://www.synelec.com.au/synergy/ – Calculator, pen and paper – Stopwatch Software – Stuttering Measurement System (SMS) http://sms.id.ucsb.edu/index.html# – Online Syllable Counter http://www.natke‐verlag.de/silbenzaehler/index_en.html – Smart phone apps: Fluency Calculator Recording system Speech Samples Sampling method – Within‐clinic – Beyond‐clinic recordings Types of speech samples – Reading – Story telling – Monologue – Conversational speech – Situation specific samples Length of sample – Time‐based – Word / Syllable‐based 300 syllables – Basic information 600 syllables 1200 syllables – Comprehensive sample Speech Contexts Best, usual and worst speaking situations Confirm ratings with client or parents/carers Individual reaction and performance to various situations Could be in different: – Environments:Clinic,home,work or community – Tasks:Conversation,phone calls,presentations – People:Spouse/partner,friends,family,co‐workers,authority CLINICAL REASONING Which language would you assess in a bilingual PWS? - What are the causes of stuttering? - Language dominance - Linguistic factors and triggers of stuttering - Client factor and language uses in everyday life Frequency, Severity and Types 1. Percentage Syllables Stuttered Percentage of spoken syllable that are stuttered Abbreviation縮寫 is %SS Identification of unambiguous stuttering moments May adopt the perceptual definition of stuttering Stuttered syllable is only counted a “one syllable” regardless of types or number or repetitions Limitations of percentage syllables stuttered – Not Viable 可行 For Self‐assessment – Reliability  2. Severity Rating Abbreviated as “SR” or “SEV” Equal-appearing interval scale to rate stuttering severity Many scale divisions, from 5 to 11-point scale Considers both stuttering frequency and behaviours 11-point scale for children; 9-point scale for adults Easy for parents / clients Need to calibrate with clinician 0= 1= 9/10 = normal speech extremely mild stuttering extremely severe stuttering “1” is not noticeable by casual observer. If any stranger or causal observer would notice the stuttering, it is at least at “3” Severity levels: – Mild:1‐3 – Moderate:4‐6 – Severe:7‐8 – Extremely Severe:9‐10 Stuttering-Like Disfluencies Stuttering-like disfluencies (SLD) – Part‐word repetition e.g. 今‐今日, wu‐wu‐玩具 – Single‐syllable word repetition e.g. 我我想, 飲飲飲水 – Disrhythmic phonation: Prolongations (e.g. f ‐ 飛機) Blocks (e.g....波) Broken words (e.g.火...車) Other disfluencies (OD) – Interjection e.g. um, er – Revision / abandoned utterances e.g. 妹妹倒瀉...打瀉杯水, 我想... 不如去公園玩啦 – Multisyllable / phrase repetition e.g. 佢地佢地好曳, 因為因為 Diagnosis criteria: – SLD≧3% Weighted SLD Diagnosis criteria: – Weighted SLD ≧ 4 [(PW+SS)xRU]+(2xDP) PW = part‐word repetition SS = single‐syllable word repetition RU = Repetition units DP = Disrhythmic phonations Types of Stuttering Johnson’s disfluency categories Clonic and tonic Primary and secondary stuttering Stuttering-like disfluencies (SLD) Lidcombe behavioural data language (LBDL) Other Speech-Related Measures Speech-Related Measures Speech intelligibility (how easy to understand) – The degree to which the utterance produced by the speaker is understood by a listener – Typical Measure in speech sound disorders. However,fluency can affect a person speech intelligibility – Intelligibility in Context Scale(ICS) Rate of speech – Speech rate:Overall time for spoken message to be delivered – Articulation rate: The rate thearticulators move for speech production – Speech rate includes both speech and disfluencies where articulation rate does not include disfluencies – Acoustic Measures Are Likely Required Communicative efficiency / competence – Speech Efficiency Score(SES) – Other Self‐rating scales Speech Naturalness (NAT) Measurement of how natural the speech sounds, usually after treatment Some treatment involves modifying the usual speech production in order to instate fluency. Resulting in speech sounding unnatural NAT is used to guide clinicians and clients to attain speech that sounds natural while being fluent 9-point equal-appearing interval scale Recent introduction of the ”Fluency Technique Scale” Stuttering-Related Quality-of-Life & Impact of stuttering Areas to Consider Awareness of disfluencies Difficulties in speaking across range of speaking contexts Strengths and coping strategies Consider psychological screeners e.g. anxiety scales Fluency-related quality-of-life 1. Overall Assessment of the Speaker’s Experience of Stuttering (OASES) Broad-based treatment outcome measure Based on International Classification of Functioning, Disability and Health Three versions: School-age, adolescents and adults Normative data in North America and Australia 100 items in 4 sections on 5-point scale – Section 1: General information about stuttering Perception of impairment, general knowledge & perception of stuttering – Section 2: Reactions to stuttering Affective, behavioral and cognitive reactions – Section 3: Communication in daily situations Difficulties experience in everyday speaking situations – Section 4: Quality of life Overall impact on quality of life Scoring: – Mild ≧ 20; Moderate ≧ 45; Severe ≧ 75 2. The Wrights and Ayre Stuttering Self-Rating Profile (WASSP) Based on International Classification of Functioning, Disability and Health (IFC; WHO 2001) No normative data For assessment and measuring treatment outcome 24 items across 2 subscales, rated on 7-point scale: – Behaviours – Thoughts – Feelings About Stuttering – Avoidance – Disadvantage 3. Communication Attitude Test (CAT) Aims of evaluate the attitude of the person towards stuttering Part of the Behavior Assessment Battery, includes: – Speech Situation Checklist – Behavior Checklist – Three versions of CAT BigCAT = The Communication Attitude Test for Adults who Stutter CAT = The Communication Attitude Test for School‐Age Children who Stutter KiddyCAT = The Communication Attitude Test for Preschool and Kindergarten Children who Stutter Standardized Assessment Standardized Assessment Stuttering Severity Instrument (SSI-4) Normed on preschool-aged, school-aged and adults Norm-referenced behavioral assessment Measures stuttering severity in four areas: – Frequency(%SS) – Duration(Three Longest Stuttering Moments) – Physica lConcomitants(Nonverbal superfluous behaviors) – Naturalness Of The Individual's Speech Physical Concomitants 1. Distracting sounds(noisy breathing, clicking sounds) 2. Facial grimace (lip pressing, jaw muscle temse) 3. Head movements (back, forward, poor eye contact) 4. Movement of extremities (arm and hand movements, leg, foot taping) A Typical Assessment Session 1. Warm-up / Rapport building 2. Case history 3. Fluency and other assessments 4. Discuss assessment results 5. Provide information about stuttering (busting myths), prognosis, range of treatment approaches etc 6. Discuss and formulate intervention plan with client and family 7. Trial treatment and recommendations/advice Class 4 Stuttering, Mental Health and Psychological Measures Stuttering and Mental Health Attitudes and Views on PWS Beliefs and Attitudes Towards PWS Shows awareness but do not understand the issues related to stuttering Shows concern or worry about having to interact with PWS SLP students have a more positive attitudes toward PWS The “accuracy” or “positiveness” of public’s belief about PWS is associated with their reaction towards PWS – More accommodating and helping behaviors e.g likely to converse with PWS – More positive affective reactions toward PWS and stuttering Stereotypes Negative attitudes toward PWS Rated as – More aroused,nervous,tense,anxious,unhappy,uncomfortable,sad,unpleasant,avoiding,embarrassed,and annoyed Moments of stuttering during interaction – Trigger negative physiological and emotional responses and gaze aversions in listeners Stuttering and Anxiety Understanding Anxiety A complex psychological event – Intense sense of tension, worry or apprehension The “expectancy of harm” leads to anxiety Components of anxiety – Verbal‐cognitive – Behaviour – Physiological Emotions of Anxiety: – Scared – Shy – Panicky – Insecure Components of Anxiety 1. Verbal-Cognitive – Expectancies of negative and harmful events in social situations – Interferes With Everyday Life And Interactions – Unhelpful Thoughts And Beliefs 2. Behavioural – Avoid Social Situations Especially Those Involve Speech/interactions – May Show Escape Behaviours(fight,flight or freeze response) 3. Physiological – Distress Leads To Physiological Symptoms – Sweating,blushing,increase heart rate,heart palpitations,hyperventilation,dry mouth,SOB,nausea, headache, shaking and muscular tension – Cognitive Symptom Eg.mental blocking,difficulty concentrating Trait Anxiety and State Anxiety特質焦慮與狀態焦慮 Trait anxiety – stable attribute – Associated With Personality And Temperament State anxiety – Immediate Response – Transient Reaction To An Adverse Situation Close association between trait and state anxiety – People with trait anxiety are more likely to experience state anxiety Stuttering and Anxiety Elevated level of anxiety across all age range Adolescents & Adults – 6‐7 folds increase odds of any anxiety disorders in adults – 4‐fold increased odds for generalized anxiety disorders in adults – Normal Range For Adolescents.However,adolescents might not provide honest response on anxiety(socially desirable responding) School-age children: – 4‐fold increased odds for any anxiety disorder – 7‐fold increased odds for subclinical generalized anxiety disorders – Anxiety is higher in the clinical cohort when compared to community sample Social Anxiety Disorder Also known as social phobia Intense fear of humiliation, embarrassment, negative evaluation and judgement by others in social and performance situations Causes social avoidance and reduce quality-of-life Expectation of humiliation and embarrassment is unrealistic and irrational when compared to the actual threat Safety Behaviours Aim to prevent feared outcome However they may: – prevent fear extinction – cause feared outcome Anxiety treatment will need to target eliminating safety behaviours However, many SLPs promotes safety behaviours to manage anxiety Stuttering and Social Anxiety Disorder PWS are more likely to have social anxiety disorder 16 to 34-folds increase odds to meet diagnosis in AWS 22-60% of AWS meet the diagnosis 6-folds increase for social anxiety disorder in school-age children who stutter However, some studies showed – Do not have social phobia but avoid social situations – Have fewer symptoms and interference of social functioning Presence of social anxiety disorder is not related to stuttering severity Not all PWS shows judgement bias or fear of negative evaluation However, socially anxious PWS – View their speech more negatively – More Likely To Avoid Speaking Situations – More emotional(e.g.symptoms of depression),social and behavioral problems – More negative thoughts beliefs Situational Speaking Anxiety Anxiety in healthy AWS More anxious in pre-speaking than post-speaking situations Anxiety is more self-perceived rather than physiological stress (cortisol level) Mood Disorder Higher rate of mood disorder in PWS 2.1 times more chance to have mood disorders Distress and negative moods – Somatization軀體化 – Interpersonal sensitivity – Depressive Mood – Hostility – Paranoia Effects of Stuttering Stigma Stigma is the feeling of disapproval / discrediting of a person based on certain characteristic Stigma are attributed to PWS being reacted to or treated negatively Most PWS experienced stigmatized behaviours during their lifetime PWS who experienced stigmatized behaviours are more likely to anticipate further negative reactions in future Teasing and Bullying CWS are at greater risks for victimization 53-77%% of PWS have been bullied CWS are less popular among peers 64% PWS reported stuttering affected friendship Social Status CWS are rejected more and less popular among peers CWS are less likely to be nominated as “leaders” but more likely to be nominated to be “bullied” CWS tend to hold lower social position Quality of Life Diminished functioning and/or quality of life in AWS No diminished general health-related QoL in preschool children who stutter Negative impact on daily life of school-aged children, adolescents and adults when using disease- specific measures Educational Attainment 80%-95% of PWS reported stuttering affected schoolwork CWS perform worse academically Lack concluding relationship between stuttering and educational attainment Taking severity into account - Negative correlation between highest educational achievement and stuttering Possible reasons: – Negative experience with teachers and peers – Decreased classroom participation – Experience negative emotions Vocational Achievement職業成就 PWS believes – Decreases Their chances to be hired – Limits Their Work Especially Requiring Communication Real-life effect – 69‐86%reported stuttering interfered with job performance – Up to 40%decreased their chance to be hired or promoted – 7.5%employment terminated Occupational stereotyping and role entrapment – 50%reported stuttering affect occupationalchoices – Jobs with lower socio‐economic status or does not require communication Financial Issue Average total cost on stuttering over a 5-year period is approximately USD $5000 Cost of early intervention (allied health, home therapy, travel, parent time) is approximately USD $4300 Major financial cost of direct and indirect treatment of stuttering, self-help, stuttering related conference, and technology Romance Adolescents and young adults consider peers who stutter less attractive Less likely to engage in a romantic relationship with PWS Psychological Measures Psychological Measures and Diagnosis Multidisciplinary team approach, especially in fluency disorders Role of a psychiatrist and clinical psychologist SLPs do NOT diagnose social anxiety or other mental health disorders SLPs may involve in the diagnostic process, management and outcome measures Some tools/tests are suitable for SLPs to administered (but not make diagnosis) Psychological Measures: 1. UTBAS The Unhelpful Thoughts and Beliefs about Stuttering (UTBAS) Scale Stuttering-specific measure with a social anxiety focus Based on common unhelpful thoughts about stuttering in PWS 66 items on 5-point equal-appearing interval scale Three subscale: – UTBASI:Experience/frequency – UTBASII:Belief – UTBASIII:Anxiety Three versions of UTBAS – UTBASscaleforadults – UTBASscaleofadolescents – UTABS‐6 Translated into 14 languages UTBAS-6 more suitable for generalist SLP and UTBAS more suitable for specialised SLP in fluency disorders 2. Psychological Measures: FNE The Fear of Negative Evaluation (FNE) Scale Measures various dimensions of social-evaluative anxiety e.g. distress, avoidance and expectations Not specific to stuttering Two versions: Original (30 items) and Brief (12 items) scales Only available for adults 3. Psychological Measures: SUDS Subjective Units of Distress Scale (SUDS) Measurement of state anxiety Usually used to evaluate/predict distress at a particular time/situation Could be made specific to speaking situations, that is for stuttering-related events 0-10 point scale or 0-100 point scale – 0=noanxiety – 10or100=extreme anxiety 4. Psychological Measures: CAT Communication Attitude Test (CAT) – CAT For CWS between 6‐15 years old – KiddyCat For CWS under 6 years old – BigCat For AWS Assesses speech-associated beliefs in PWS Negative communication attitude may be related to social anxiety 5. Psychological Measures: SCAS The Spence Children’s Anxiety Scale (SCAS) Well established scale with normative data Not specific to communication or stuttering Not for diagnosis but measures the nature and extent of anxiety symptoms Three versions: – SCASchild(8‐15years) – SCASpreschool(3‐5years) – SCASparent 6. Psychological Measures: PASR Pre-school Anxiety Scale – Revised (PASR) Parent report measure for children under 6 years of age Not a diagnostic instrument but identifies elevated anxiety symptoms Not specific for communication or stuttering 4 subscale: – Social anxiety – Generalised anxiety – Separation anxiety – Specific fears Psychological Management of PWS Treatment Outcome and Mental Health 64 adults with speech restructuring treatment 2/3 with one or more mental health disorders Mental health group has higher pre-treatment severity Mental health group has lower treatment gain (make less progress) High treatment relapse 復發 in mental health group Psychological Management Psycho-social impact of stuttering No clear relationship between stuttering severity and psychological variables (Prins, 1972; Stein et al, 1996; Menzies et al, 2008) Impede 阻礙 treatment progression and outcome Multidisciplinary approach to management: – Clinical psychologist – Psychiatrist – Speech‐language pathologist(we are not trained and qualified to diagnose and manage social anxiety or mental health issues!!) Conflicting principles between direct stuttering therapy and social-anxiety treatment – Induce and increase Self‐focused attention – Promote use of safety Behaviour – Stuttering therapy becomes a safety behaviour No strong evidence on the order of treatment – Psychological treatment first or speech therapy first – May need a detailed assessment to evaluate the most impacting issue Psychological treatment reduces social anxiety but NOT stuttering severity Counseling People who Stutter Integral part of treatment More likely for adults, but also important school-aged or preschool-aged children who stutter as well as parents Basic counseling skills is required Consider referral to professionals, if appropriate 1. Cognitive Behavioural Therapy CBT Strong evidence of CBT in managing social anxiety, and especially in PWS Hopefully prevent relapse Reduce negative evaluation and stereotyping experienced by PWS Social anxiety may worsen stuttering In-person and online standalone treatment available Four Components of CBT 1. Exposure – Gradually expose to fearful / anxious situations – Practice fluency in increasingly difficult and feared situations – Develop fear hierarchy – Counter threat‐related experience (e.g. people will laugh at me) – Evaluate and justify expectancies of harm 2. Behaviour experiments – “Voluntary stuttering” – Using fear hierarchy – Compare predicted outcome to real‐life outcome – Continue to form new predictions 3.Cognitive restructuring – Challenge negative beliefs and judgments – Give evidence for and against negative thoughts – Let go of outcomes beyond control – Evaluate usefulness of unhelpful thought/beliefs – Consider the real cost or severity of possible negative outcomes 4. Attentional training – Reduce threat‐related intrusive thoughts – Increase control where attention is placed – Attend to alternative cognitive targets – Use a simple meditation breathing procedure Acceptance and commitment therapy 2. Acceptance and Commitment Therapy (ACT) Focuses on awareness, acceptance and understanding the context of thoughts rather than challenging and changing them Incorporates mindfulness training – Mindfulness–increaseawarenesstopayattentiononpurposetothepresentmoment;beingnon‐ judgemental to unfold the experience Emerging studies/evidence on using ACT with PWS – may have benefits or useful as part of fluency treatment Class 5 Stuttering and Multilingualism Introduction to Multilingualism Multilingualism: A Brief Introduction Terms: – Monolingual – Bilingual – Multilingual Ways to become bilingual – Simultaneous Bilingual Learn both languages from birth or soon after birth – Sequential Bilingual Learn both languages one after the other Languages spoken by a bilingual person: – Dominant Language The more proficient language – Non‐dominant language The less proficient language – L1 First language learned by a sequential bilingual – L2 Second language learned by a sequential bilingual Balanced bilingual – A Person Who Is Equally Proficient In Both Languages Does multilingualism contribute to stuttering? Stuttering in Multilingual PWS Stuttering Prevalence Conflicting findings in the literature Bilingual speakers are more likely to stutter and are less likely to recover naturally No difference in the likelihood of stuttering between monolingual and bilingual Many methodological flaws Au-Yeung et al (2000) – Online survey of 794 Individuals – 40 countries;L1=52andL2=70 – Participants Age:3‐80 years of age – Same prevalence in monolingual and bilingual,especially in early bilingual groups Some Convergent收斂 Findings Monolingual and multilingual children who stutter: – Similar Male‐to‐female ratio – Onset Age – Higher Recovery Rates In Female – Positive Family History Of Stuttering Stuttering Frequency Stutter in all the languages they speak Findings in the literature are controversial: – Stutter More In Less Proficient Language – Stuttermoreinmore Proficient Language – Balanced Bilinguals Stutter more in one language – With Many Methodological Flaws Shafer & Robb (2012) – 15 German‐English bilinguals (Age10–59;Meanage=25) – More stuttering in L2 than L1 – L1:More Stuttering On Content Than Function Words – L2:Similar stuttering frequency on content than function words Maruthy, Raj, Geetha and Priay (2015) – 25 Kannada‐English Bilinguals(Age16–28;Meanage=22.5) – More stuttering in L2 than L1 – L1:More stuttering on content than function words – L2:More stuttering on function words Woumans, Van der Linden, Hartsuiker et al. (2021) – 28 Dutch‐FrenchandDutch‐English Bilinguals(Age19‐53) – More SLD in L2 than L1 Krawczyk, Vanryckeghem, Wesierska, Kong and Xu (2023) – 7 Polish‐English Bilinguals(Age20–31;Meanage=25;8) – More stuttering in L2 than L1 in speech tasks (dialogue, monologue and reading) – More typical disfluencies in English Lim, Lincoln, Chan and Onslow (2008) – 30 Mandarin‐English Speakers Between 12‐44 years‐old – 15 English‐dominant; 4 Mandarin‐dominant; 11balanced – Significantly More Stuttering In Less Dominant Language, but marginal clinical difference Why? – Linguistic Demands – Cognitive demands(Dual Tasking) Stuttering Behaviours Bilinguals produced both SLD and OD in all languages spoken BPWS produce more SLD than typical disfluencies in both languages but more typical disfluencies in L2 Lim et al showed no differences between each stutter behaviour However, under dual task situations... Woumans, Van der Linden, Hartsuiker et al. (2021) – Bilingual PWS produce more typical/normal disfluencies in L2 – Attention to speech appear to speech appear to change dysfluencies across languages CLINICAL REASONING What’s your take on this? What are the causes of stuttering? Underlying? contributing /modulatingg factors? Need of the family Many of these studies have methodological concern -definition of bilingualism -coincide introduction of second language with stuttering The “Mis diagnositic” Criteria Multilingualism increases the chances that a person will be misdiagnosed as stuttering 44.8% typically fluent children misidentified as stuttering and missed diagnosis on 12.5% CWS Frequency of stuttering: Monolingual diagnostic criteria: >3%SLD Fluent multilingual children exceed this norm Behaviours of stuttering: Repetition: Sound and whole word L2 contains both stuttering-like disfluencies and typical disfluencies 41% of studies used monolingual criteria to diagnose BCWS The consensus to date... 1. Insufficient data to suggest stuttering is more prevalent in bilinguals/multilinguals 2. Learning another language does NOT increase the risk of developing or for onset of stuttering 3. The stuttering in multilingual/bilingual CWS will be different to multilingual/bilingual AWS, due to language proficiency changes overtime – Exposure – Development – Attrition 消耗 Management for Bilingual PWS Cultural Beliefs and Practices of Stuttering Cause of stuttering Cutting child’s hair before first word Allowing infant look in the mirror Failure to inform ancestors of childbirth Offended “God of Tongues” Pregnant woman drinks from a cracked cup Work of the devil Remediation of stuttering Bury hyoid bone of a lamb in the house Smack the person’s face when it rains Drink sea water  Apply a hot metal tool or knife to the PWS Apply ointment to the throat Prayer Assessment of Multilingual PWS CLINICAL REASONING What are possible issues? -can I identify stuttering in another language? -can I describe the behavior accurately? - can I rate stuttering frequency accurately? -How can i conduct the assessment? How do I interact with the client? -What about cultural issues? Identifying Stuttering in Another Language Possible influencing factors: – Familiarity Of The Other Language – Closeness of the other language to your own language – Experience In Working With Stuttering – Severity Of Stuttering What does research say? Einarsdotti et al (2009) – Identification Of Stuttering Moments – Icelandic vs American SLPs rating both Icelandicand English samples – Experience of SLP is the most important factor – Reliability Of Identification Is Similar In Both Groups(i.e.language familiarity is not an issue) Cosyns et al (2015) – Accuracy In Rating Stuttering Severity – Icelandic,Swedish,Norwegian,FinnishandBelgianSLPs – Stuttering Severity Of The Client Is The Most Useful(the more severe the easier) – For mild‐moderate stuttering severity: closeness of language and experience stuttering will help increase accuracy Bosshardt et al (2015) – Measuring Stuttering Severity – 170SLPs:Danish,English,French,German,Greek,Italian,Persian(Farsi‐speaking) – Agreement of rating was similar and not affected by familiarity with the language – Experience in stuttering did not contribute to the rating reliability – Familiarity of the language is useful for rating stuttering in less proficient languages Assessment of Bilingual PWS Assessing multilingual status – Comprehensive history of language and multilingual development – Identify Language Proficiency/dominance – Use of interpreter to“interpret”both linguistic and cultural aspects of language Fluency assessment – Details Case history:familyhistory,onsettime,trajectory stuttering – Stuttering Severity Varies Across Languages – Stuttering Behaviours In Each Language – Multiple speech samples(variability of stuttering;cognitive and linguistic load) – Counterbalance Language Across Task(adaptation effect) – Perception And Effects Of Stuttering Some other suggestions: – Experiencemattersinidentifyingstuttering(maynotbeforseverity) – Someunderstandingofanotherlanguagemayassistinstutteringidentification – Consensusraterwhoisfamiliarwiththeclient’slanguage – Understandingofculturalbackgroundandhowitaffectslanguageselectionandassessmenttask – Rateshorterintervalsofspeechsample – Cautionaboutnormaldysfluenciesinnon‐dominantlanguage(anddominantlanguage) Differential Diagnosis: Stuttering vs Disfluencies Better (and accurate) diagnostic guideline/criteria for multilingual PWS is urgently needed Types of stutter: dysrhythmic types, tension, co- occurring stuttering Self-reported (parent-reported) stuttering (internal definition) for older individuals Treatment of Multilingual PWS Personal, Cultural and Language Factors Deferring the introduction or withholding one language is not recommended Carefully consider cultural and personal influences on intervention intention, treatment selection and therapy targets Consider the language of intervention – May Need To Practice In Both Languages – Plan for generalization the other language Cultural and linguistically appropriate treatment materials and stimuli Involve parents into therapy Treatment Outcome in Multilingual Stuttering Druce, et al., 1997 – 15 children aged between 6‐8 – 6/15 children were bilingual – Operant treatment plus speech restructuring treatment – No Significant Effect Of Bilingualism On Speech Outcome Waheed-Khan, 1997 – 20 bilinguals and 20 monolinguals – Fluency Shaping Treatment – Monolinguals Perform Better Than Bilinguals – Include family member participation: Similar outcome in both groups Findlay, Shenker and Matthews, 2008 – File audit 33 monolingual and 23 bilingual children aged between 2;9 – 11;9 – Lidcombe program – No difference between the time reaching stage 2 and benchmark of Lidcombe Program Generalisation: Operant-Based Treatment Roberts and Shenker, 2007 – Single Case A3;11English‐French speaking child – Lidcombe program in English initially and French from week7 – Pre‐Tx(EnglishandFrench):5.6–8.8%SS – Post‐Tx:English=0.6%SS;French=0.9%SS Bakhtiar & Packman, 2009 – 8;11 Persian‐Baluch Speaking Boy – LidcombePrograminPersian(clinic)andBaluchiandPersian(home) – Pre‐Tx:BaluchiSR=5;Persian=12%SS – Post‐Tx:bothlanguages