Fluency

Question 1

What are the general Tx goals in stuttering?

Answer 1

• Achieving a reduction in the amount of stuttering; if possible, reducing all dysfluencies to within normal limits
• Establishing normal sounding fluency that is naturally produced, without special techniques, strategies, or unsustainable attention to certain ways of talking (ex. excessively slow speech)
• Reducing associated motor behaviours that make the stuttering worse
• Reducing avoidance and negative feelings about speech
• Counselling client and their family

Question 2

Treatment method that works with many young children to positively reinforce fluent speech in naturalistic conversational contexts.

Answer 2

Fluency reinforcement method

Question 3

Treatment method that teaches person who stutters to pause after each dysfluency and then resume talking.

Answer 3

Pause-and-talk

Question 4

What’s something that’s important to work with parents when it comes to their child’s stuttering?

Answer 4

Counselling their parents and the child on not only handling bullying from other children, but all negative reactions from others is important.
- Ex. When a child bullies another child, they can say “you know, sometimes I have difficulty saying certain words but I am working on it”. If the child say that, teach parents, siblings or teachers that could help and step in

Question 5

Can pharmacological Tx replace the behavioural methods to treat stuttering?

Answer 5

No; all are still experimental. Tranquilizers/sedatives may reduce the severity of stuttering, but side effects contradict their use.
Drugs that interfere with the uptake of dopamine have been used.

Question 6

In older students/adolescents, what type of therapy could be useful for stuttering?

Answer 6

Fluency shaping and pause-and-talk are two good choices.

Question 7

Type of stuttering that is associated with documented neuropathology - often in older individuals

Answer 7

Neurogenic stuttering

Question 8

What’s the most frequent cause of neurogenic stuttering?

Answer 8

CVAs that causes strokes

Question 9

Rapid but disordered articulation and resulting indistinct (unintelligible) speech

Answer 9

Cluttering

Question 10

How is cluttering assessed?

Answer 10

Like stuttering, but with an emphasis on its special features (excessive rate and rate variations, articulatory breakdowns and speech intelligibility)

Question 11

Type of stuttering that is faked exhibited to gain an advantage from the problem; symptoms are well planned (research by the individual); the individual knows he/she is faking.

Answer 11

Malingered stuttering

Question 12

Type of stuttering in which the origin is unknown to the individual; may be associated with depression, anxiety, PTSD, and other psychiatric disorders

Answer 12

Psychogenic stuttering

Question 13

What case history information should you make sure to include for a child with fluency issues?

Answer 13

Family history
Other language development history
Other developmental milestones

Question 14

What is developmental disfluency?

Answer 14

DD is a part of normal speech fluency development when the young child is learning language
The term DD is used to describe the speech fluency of a preschool age child who primarily is producing repetitions of words and phrases, interjections and revisions

Question 15

What are the characteristics of a fluency disorder?

Answer 15

Repetitions: sound, syllable, or single syllable (ex. can)
Prolongations: movement of articulators stops during gesture and speech sound is either audible (resulting in lengthening of sound) or inaudible
Blocks: articulates are in a fixed position but no airflow or voicing is produced
These are also referred to as the core or primary behaviours

Question 16

What issues might you see in breathing/respiration for an individuals with a stutter?

Answer 16

Clavicular vs. diaphragmatic (often will use their clavicle (upper parts of their shoulders) rather than their diaphragm
Audible (or inaudible) inhalations within phrases/words (not at typical times)
Running out of air when speaking (some children then don’t take another breath and then they get into vocal fry)
Speaking below resting expiratory level
Not using air for speech

Question 17

What issues might you see in voicing/phonation for an individuals with a stutter?

Answer 17

Vocal fry

Hard glottal attacks

Question 18

What issues might you see in articulation for an individuals with a stutter?

Answer 18

Hard contacts

Difficulties with specific sounds.

Question 19

What is developmental stuttering?

Answer 19

Abnormally high frequency/duration of stoppages in the forward flow of speech, taking the form of repetitions, blocks or prolongations. Speakers who stutter usually react to these stoppages by trying to force words out, or by or using extra sounds, words, movements in their efforts to become ‘unstuck’ or to avoid getting stuck.
Accompanied by:
○ Secondary behaviours: Escape behaviours (e.g. eye blinking and head nodding or other movements of
the extremities, body or face), Avoidance behaviours (i.e. avoidance of sounds, words, people or situations that involve speaking)
○ Physical tension
○ Negative thoughts/emotions
○ Decreased communication skills
○ Involuntary breakdowns affects all communication (e.g. respiration, phonation, articulation, the three systems of speech)

Question 20

What are some causes of developmental stuttering?

Answer 20

Multifactorial; there is no one cause of stuttering, but multiple systems play a role (i.e. genetic, neurophysiological factors, environmental, abnormal phonation system, etc.). Most common form of stuttering.

Question 21

What are some predisposing factors for developmental stuttering?

Answer 21

Family history - many people who stutter have a family member who also stutters
Brain differences - people who stutter may have small differences in the way their brain works during speech

Question 22

What is neurogenic stuttering?

Answer 22

Neurogenic stuttering is an acquired fluency disorder that typically occurs following some sort of injury or disease. In the majority of cases, the injury or disease that caused the stuttering can be identified. The brain has difficulty coordinating the different components because of signalling problems between the brain and nerves or muscles.

Question 23

hat are some causes and predisposing factors for neurogenic stuttering?

Answer 23

Causes: damage to the central nervous system (i.e. brain and spinal cord). Most often from stroke, and secondly from a TBI, but other injuries and diseases include Ischemic attacks, tumors and cysts, degenerative diseases (e.g. Parkinson’s) and drug-related causes
Predisposing factors: can occur at any age; however, it appears more often in adulthood, and the highest incidence is in the geriatric population

Question 24

What is psychogenic stuttering?

Answer 24

Psychogenic stuttering is also an acquired fluency disorder
Causes: It typically results from emotional trauma or emotional stress. Causes can include anxiety, depression, conversion disorders, and emotional responses to traumatic events. It is abrupt, sudden, involuntary, and often related to an identifiable event.
Predisposing factors: It is associated with a psychological disorder. However, in two different individuals experiencing the same trauma, one (or both) may never develop stuttering at all.

Question 25

What is cluttering?

Answer 25

Rapid speech with high rates of disfluency and irregular prosody. Decreased intelligibility.
Characterized by a perceived rapid and/or irregular speech rate (i.e. talks too fast, sounds jerky), atypical pauses, maze behaviors, pragmatic issues, decreased awareness of fluency problems or moments of disfluency, excessive disfluencies, collapsing or omitting syllables, and language formulation issues, which result in breakdowns in
speech clarity and/or fluency.

Question 26

What are the causes and predisposing factors of cluttering?

Answer 26

Causes: research is not far enough along to identify causes of cluttering
Predisposing factors: potential factors include:
○ Age - more often occurs in school-age children.
○ Sex of child - appears to be more common in males
○ Family history - anecdotal reports indicating presence of cluttering in more than one family member suggest that family history may be a risk factor
○ Presence of co-occurring disorders - features of cluttering are sometimes observed in conjunction with other neurological disorders (e.g. ASD, Tourette’s, and ADHD). However, not all individuals with these disorders also exhibit cluttering.
○ Presence of stuttering - an estimated one third of people who stutter also present at least some components of cluttering

Question 27

What is acquired stuttering?

Answer 27

A general term referring to a type of fluency impairment that arises secondary to a specific causal event such as stroke, head trauma, neurodegenerative disease, introduction of a pharmacological agent, or significant psycho-emotional stress

Question 28

Compare and contrast developmental and acquired stuttering.

Answer 28

Similarities: involves primary/core behaviours and are associated with behavioural symptoms
Differences:
Lesion: unknown but includes left perisylvian areas (develop) vs. cortical or subcortical in either hemisphere (acquired)
Cause: unknown vs. physical trauma, vascular, metabolic, tumour
Duration: 80% grow out of vs. good prognosis if unilateral, bad if bilateral
Dysfluency: beginning of sentence or phrase vs. scattered throughout sentence
Singing: induces fluency v.s. may minimally improve fluency
Onset: sub-acute vs. sub-acute or acture
Reaction: anxious vs. not anxious

Question 29

What is true about acquired fluency disorders?

Answer 29

(i) roughly equal occurrence of dysfluencies on both content and function words
(ii) lack of anxiety about disfluencies;
(iii) stuttering instances not restricted to initial syllables;
(iv) rare occurrence of secondary behaviors;
(v) absence of adaptation effect; and
(vi) occurrence of dysfluencies on all speech tasks.

Question 30

Describe an ideal speech sample for a fluency disorder

Answer 30

Shows frequency, duration, types, and secondary behaviours
Should be between 200-500 syllables
Sample a variety of communicative contexts and across environments

Question 31

What can affect stuttering that may make it difficult to obtain a representative sample?

Answer 31

Variability is one of the hallmarks of stuttering. Things that can impact the sample include:
The speaking task (i.e. the activity in which the speaker is engaged)
- E.g. reading, describing a picture, retelling a story, describing a job
The conversational setting (i.e. the location in which the seaking is taking place)
- E.g. in the clinic, at home, in the classroom/workplace, on the playground
The conversational partner (i.e. the person with whom the client is speaking)
- E.g. clinician, peers, parents, siblings, spouses, co-workers

Question 32

How could we assess the psychosocial impact of a person’s stuttering?

Answer 32

Social/pragmatic skills; Verbal interactions in familiar and unfamiliar situations; Number of opportunities for the client to use new skills in realistic speaking activities; Strategies for dealing with bullying; Self-advocacy strategies, Expressing wants and needs, Having conversations or telling stories, Forming relationships, regulating emotions, showing confidence and conveying truthfulness
Assess: case history, comparison of speech samples, self-report

Question 33

How could we assess the educational/linguistic impact of stuttering?

Answer 33

Linguistic complexity,MLU, presence/absence of word avoidance, reading aloud and answering short questions
Assess: classroom observation, interview, self-report measures.

Question 34

Name some intervention types for fluency disorders.

Answer 34

Feedback technology
Cognitive interventions
Behavioural interventions
Speech motor intervention
Speech motor + cognitive
Multiple component
Fluency shapping
Stuttering modification
Pharmacological options

Question 35

Describe feedback technology.

Answer 35

Technologies that aim to reduce frequency or severity of stuttering but altering the way a person with stuttering hears their own speech
Two types: frequency altered feedback (FAF) and delayed auditory feedback (DAF)
Some devices also combine these two

Advantages: all have a positive effect on fluency, no adverse outcomes
Limitations: most participants are adults, results are variable across individuals.

Question 36

What are cognitive interventions?

Answer 36

Aim to lead to psychological change and may be used alone or to support, optimize or prepare for other interventions
Anticipated outcomes: direct speech gains, psychological wellbeing gains which lead to improved speech, gains which aim for living successfully

Pro: positive impact on measured outcomes, reduced stuttering severity, positive communication attitude, improved speech fluency, self-efficacy beliefs, coping, and attitudes towards speech situations
Con: evidence for adults only, certain tools to measure outcomes have significant limitations.

Question 37

What is behavioural modification?

Answer 37

Focuses on changing the behaviour of child or family
Lidcombe program: teaches parents to provide verbal contingencies on the child’s fluent and stuttered speech
Parent-child interaction therapy: focus on changing behaviours within family, predominantly parent behaviour and interactions
Direct child behaviour modification: working exclusively and directly to change approach
Pros: used with all ages, lidcombe has shown good improvements, benefits post-intervention, positive effects on %SS and severity of stutter.
Cons: requires involvement and persistence of parent/caregiver

Question 38

What are speech motor interventions?

Answer 38

Clinical administered direct therapy approach that aims to reduce stuttering by altering speech motor patterns (eg. easy onset, measured rate)
Focuses on the mechanism of speech and includes fluency shaping techniques that aim to establish fluent speech by altering it significantly and then shaping it to sound more natural
Pros: all studies reports positive benefits, reduced %SS
Con: most with adults or older children

Question 39

What are speech motor+cognitive interventions?

Answer 39

Combines cognitive techniques with speech motor/fluency shaping techniques
Elements: EMG feedback, smooth speech, relaxation, airflow training, social support, self-management components, elements to prevent relapse.
Pros: all report positive impacts, some reduction in %SS, positive effects on reducing avoidance behaviours and anxiety surrounding speech
Cons: some fading after intervention, change in attitudes towards speech after technique sessions.

Question 40

What are multiple component interventions?

Answer 40

Incorporate multiple components of components of different fluency interventions
Elements: EMG feedback, smooth speech, relaxation, airflow training, cognitive aspects, self-management components, social support, particular elements to prevent relapse
Pros: any age, positive impact on avoidance behaviours and attitudes, reduction in self-judgement, reduction of #SS and %SS
Cons: complex to implement

Question 41

What is fluency shaping?

Answer 41

Techniques that alter breathing, speech rate, voice production, and articulation in ways that facilitate more fluent speech
Maintenance of fluency by modifying the manner of speaking and contingencies for stuttering and fluency
Include skills such as: relaxed breathing, belly breathing, slow stretched speech, smooth movement, easy voice, light contact/soft touch
Therapy is characterized by conditioning and programming principles

Advantages: explains systems of speech and which element is being targeted, motivating from start of program, almost all can become highly fluent quickly
Cons: may require abnormal speech patterns, can sound unnatural, some difficulty with maintenance and fear of stutter returning, does not address underlying fears and concerns, requires use of contingent reinforcements

Question 42

What is stuttering modification?

Answer 42

Work directly with stuttering to help client increase awareness of stuttered speech, examine and reduce physical tensions, and ultimately change moments of stuttering.
Help reduced struggle behaviours and stutter in a more relaxed way.
Can also help decrease sensitivity, negative reactions, and increase feelings of control, openness, and acceptance.
Techniques: catching the stutter, relaxing the stutter, slide, easy stuttering, cancellation

Pros: no abnormal pattern, therapy is more spontaneous and enjoyable, helps understand the nature of their concerns and become less anxious, more natural speech, flexible approach
Cons: non-structures and more difficult decisions beed to be made, high degree of clinical skill, may not be the best for more severe

Question 43

What are the pharmacological options for stuttering?

Answer 43

Excess levels of dopamine in the BG may lead to stuttering
Some drugs block DA to improve fluency
Pros: reduced by 50%
Cons: limited reduction, does not address other issues, other factors (side effects, interactions with other drugs, risk to health and safety)

Question 44

Name the possible service delivery models for disfluency and some examples

Answer 44

Parent training/counselling: can set minds at ease, educate and clear conceptions, answer questions, provide strategies
Parent training: slow speech/turtle talk
Home/school programming: fluency shaping programs (lidcombe, syllable-timed speech, palin parent-child interaction)
Individual therapy: Stuttering modification programs - Cancellation technique (post-block correction) Pull-out technique (In-block correction), Preparatory set technique (pre-block correction)
Group therapy: stuttering modification programs, support, share ideas and resources

Question 45

What are some interaction strategies for parents of children with stutters?

Answer 45

Follow your child’s lead in play
Make more comments and ask less questions
Keep the complexity of questions at the child’s level
Use language appropriate to the child’s level
- Use language that is contingent on the child’s focus
Repeat, expand, and rephrase often
Allow child time to initiate, respond, and finish their statements (don’t complete
sentences for them)
Maintain eye contact, position, touch
Provide constant praise and encouragement

Question 46

What are some possible targets for disfluency intervention?

Answer 46

Reducing rate of speech
Stretching out speech
Regulating and controlling breathing
Establishing light articulatory contact
Facilitation of oral-motor planning coordination
Modifications of the stuttering moment
Self-monitoring
Transfer and generalization

Question 47

Talk about family studies in stuttering.
1. Is there a higher prevalence in families?
2. Twin studies?

Answer 47

Genetic predisposition
o Prevalence x3 higher in families who stutter
o Family prevalence increases in families with daughter who stutters (inherited stronger predisposition)
o Males more at risk to develop persistent stuttering
o Females tend to recover from stuttering more easily

TWIN STUDIES
o Monozygotic (identical twins) have more concordance than fraternal
o Not 100% in identical twins à only 1 twin stutters
o Environmental factors play a role

Question 48

What are recovery predictors without treatment?

Answer 48

When a child’s family includes stutterers whose stuttering persisted (lack of family history)
o Boys have a greater risk of persistence, but girls typically recover more quickly
o Children who begin to stutter “later” (after 3.5 years)
o Children whose stuttering frequency/severity is not decreasing over a year after onset
o Longer the child stutters beyond a year after onset, the greater the risk of persistence (especially for girls)
o If prolongations + blocks do not decrease as stuttering goes on
o Children whose phonological skills below norms

Question 49

What are factors that contribute to increases in normal disfluencies?

Answer 49

Demands of language acquisition
o Ineffcient speech-motor control skills
o Interpersonal stress associated with growing up in a typical family
o Threats to security (divorce, hospitalization, relocation)
o Under normal daily pressures of competition + excitement while speaking

Question 50

Is parenting a cause of stuttering?

Answer 50

Parents are NOT the cause of stuttering - there’s no difference in communication/interaction

• If parent is a fast talker = speaking rate may maintain stutter
• SLP could work with parents on their communication style to help with therapy success
• Some parents have unrealistic standards of fluency = normal disfluency misdiagnosed
• Parents find it difficult to cope with having a child who stutters