Fluency Final

Question 1

Fluency Definition

Answer 1

effortless flow of speech

Question 2

Stuttering Definition

Answer 2

Culatta and Goldberg’s definition: a developmental communication disorder, beginning in childhood, of unknown origin, that results in a person viewing the communication process differently from a normal speaker due to experiences with overt or covert factors that disrupt normal communication

Question 3

Cluttering Definition

Answer 3

ASHA definition: a fluency disorder characterized by a rapid and/or irregular speaking rate, excessive dysfluencies, and often other symptoms such as language or phonological errors and attention deficits

Question 4

Neurogenic Dysfluencies

Answer 4

usually adult onset stuttering caused by head injury, stroke, degenerative disease of the CNS, brain tumor, brain surgery, and drug induced brain dysfunctions.

Question 5

Psychogenic Dysfluencies

Answer 5

hysterical or conversion reaction as a result of emotional trauma

Question 6

Malingering Defintion

Answer 6

occurs if a person who does not stutter presents as if he or she does to obtain some type of benefit

Question 7

Spastic Dysphonia

Answer 7

(sometimes called laryngeal stuttering) may be covered in Voice

Question 8

Manual Communication

Answer 8

part and whole word repetitions of hands

Question 9

Wind Instruement

Answer 9

has occurred with musicians who stutter

Question 10

Acquired Stuttering Following Laryngectomy:

Tourette Syndrome

Answer 10

characterized by chronic tics (repetitive, rapid, sudden, involuntary movements or utterances)

Question 11

Acquired Stuttering Following Laryngectomy:

Mixed Dysfluency

Answer 11

can occur if a person who stutters develops one of the conditions listed above.

Question 12

Who stutters? Who is likely to stutter?

Answer 12

Over 3 million Americans (approximately 1% of the general population) stutter (Mansson, 2000)

Prevalence and incidence figures will vary. For every study providing one set of numbers, there may be another study providing a different set of figures. For example:

Stuttering incidence reported in 21st Century studies, Yairi & Ambrose, 2013

Question 13

Professional Issues

Answer 13

All people with the CCC are qualified to treat any communication disorder (think the Big Nine)
All people with the CCC are held to the ASHA Code of Ethics which states that if we are not able to treat a disorder, we shouldn’t – even though on paper we may seem qualified.
Every person who holds the CCC should not treat stuttering even if though they hold the credential.

Question 14

What is Clinical Specialty Certification?

Answer 14

…. a means by which audiologists or speech-language pathologists with advanced knowledge, skills and experience beyond the Certificate of Clinical Competence (CCC-A or CCC-SLP) can be recognized by consumers, colleagues, referral and payor sources, and the general public. The American Speech-Language-Hearing Association (ASHA) initiated the Specialty Recognition Program in 1995 (now known as clinical specialty certification).

Question 15

What are the key components?

Answer 15

Completely voluntary—the program is predicated on the expectation that the majority of ASHA members will continue to practice as generalists.

Non-exclusionary—holding specialty recognition in an area is not required in order to practice in that area.

Member-driven—the establishment of Specialty Boards in areas of specialized clinical practice depends on the initiative of groups of ASHA members to submit petitions to the CCSR.

Question 16

Core Characteristics of Stuttering in General

Answer 16

Repetitions – 2 or 3 types
part-word repetitions – repeating a sound or syllable; usually at the beginning of words
whole-word repetitions - saying the same word several times

some SLPs choose to specify “sound rep”, “syllable rep” or “word rep”; some say “repetitions”

Repeat the consonants in the onset position in your first name 3 times; Then do it again, but repeat the onset consonant + a vowel
Prolongations - airflow continues but the movement of the articulators is stopped

When we sing, we prolong sounds.

Blocks - inappropriate stopping of the airflow or voice; articulators often stop as well;
considered to be one of the last characteristics to occur; accompanied by tremors in severe cases

Guitar’s example: try to say the word ‘by’ while squeezing your lips together

Question 17

Secondary Behaviors (or Characteristics)

Answer 17

Associated Motor Behaviors that the PWS often uses in an attempt to speak fluently, these are not always conscious on the part of the speaker. You may also see the term physical concomitants. Guitar classifies them as escape or avoidance behaviors.

Question 18

Escape

Answer 18

speaker stutters and tries to stop it by doing something like

Question 19

List of some secondary behaviors

Answer 19

Poor eye contact
Facial grimace
Facial flushing
Unusual lip position
Pressing lips together
Excessive mouth opening
Eye blinks
Closing eyes
Jaw movement
Head jerks
Bending head down
Extraneous body movements
Holding breath
Irregular breathing
Speaking on supplemental air
Glottal fry
Tremor

Question 20

Avoidance

Answer 20

speaker anticipates stuttering so he/she resorts to behaviors to not stutter like:
Some of the above

Question 21

Interjection

Answer 21

(any word or sound that does not form a linguistic function); more on this later
changing the planned (feared) word

Question 22

Feelings and Attitudes

Answer 22

Feelings associated with stuttering can be very strong. The person who stutters may recall painful moments of stuttering for years and years. Feelings and stuttering are often intertwined to the point that it may not be easily discerned when the stuttering leads to negative feelings and when negative feelings lead to stuttering. Some feelings include:
Frustration
Shame
Fear
Guilt
Hostility
Attitudes are deeply rooted feelings. They reflect the depth of the pain and struggle felt by many because of the stuttering. Those attitudes can subsequently shape behavior.

Question 23

Moments of stuttering and their relationship to…

Answer 23

phoneme - consonants more than vowels
* position - beginning of word or syllable, beginning of the utterance
* grammatical function - nouns, verbs, adverbs and adjectives more
* word length - more likely on longer words (more syllables)
* speaker’s familiarity with the word – less stuttering if more familiar
* syllable stress - more likely on stressed than unstressed

Question 24

Concomitant disorders

Answer 24

Articulation and phonology

• young children who stutter are more likely to exhibit speech sound errors than children who do not stutter
• of all the speech and language problems that co-occur with stuttering, artic and phono difficulties are among the most common
• in cases of severe phonological disorder, think about cluttering

Question 25

Concomitant Disorders

Answer 25

Language

• how might stuttering impact the various components of language?
• assess language when assessing fluency? why or why not?

▪ Word finding
▪ confrontation naming
▪ word association

Question 26

Child Rearing

Answer 26

while we no longer blame parents for causing their children to stutter, there are certain parental behaviors that are conducive to stuttering while yet others are conducive to fluency

Question 27

Learning Styles

Answer 27

you must learn new strategies and behaviors in order to become fluent; how you learn is largely related to the learning style of your community

Question 28

Interaction rules and reactions

Answer 28

who displays what behavior around which people is cultural also; eye contact which we think might be important for a PWS, may not be important if you are from a culture that does not value that behavior

Question 29

Emotions

Answer 29

the feeling(s) people have about their problem may to a large extent be related to their culture and to the reactions of friends and people with whom they interact regularly – especially if that society places great importance on fluent speech; how you display emotions is largely cultural in nature

Question 30

Gender/sex in regards to stuttering

Answer 30

There is unequivocal evidence that more males than females stutter, regardless of the society or national origin.

Question 31

Parent/ Variables/Child-Rearing Practices

Answer 31

Glasner (1949) identified harsh discipline, humiliation, and indulgence as directly affecting the occurrence of stuttering

Question 32

Demographics

Answer 32

Stuttering is more prevalent in urban, rather than rural areas, according to Brady and Hall (1976), Yet, Dykes (1995) found that rural areas had a greater prevalence of stuttering (49%) than urban areas did (34%)

Question 33

Bilingualism

Answer 33

Bilingual children are more likely to stutter than monolingual speakers, according to Bloodstein (1995) and Borsel et al (2001) who cites a prevalence rate of 2.8% among bilinguals versus the nearly 1% in the general population. In contrast, Montes and Erickson (1990) found no significant differences in the occurrence of stuttered speech behaviors in English and Spanish bilingual children. They also noted that the types of disfluencies associated with second language learning are often misindentified as stuttering.

Question 34

SES Class

Answer 34

Morgenstern (1956) found more stuttering in the middle and upper-middle classes than in the lower classes.

Question 35

Race/Ethnicity

Answer 35

Dated studies examined stuttering among the Eskimos and native Americans; however no current research is available on these groups nor on Asian Americans. Leavitt (1974) found the prevalence of stuttering among Puerto Ricans living in New York City to be 0.84%, a value similar to that of whites; by comparison the prevalence among of Puerto Ricans living in San Juan was 1.5%.

Question 36

Assessment Questions Foundations
Does the problem seem to be the result of a neurologic Suggested questions for the SLP to ask about a motor speech evaluation (Duffy (2013), Swigert (2010):

Answer 36

Is there a problem with the patient’s speech?
– If there is a problem, what is the best way to describe it?
– Does the problem seem to be the result of a neurologic disorder?
– If it seems to be neurologic in origin, did it appear suddenly or slowly?
– Is the problem related strictly to speech production, or is it more of a problem with language, such as aphasia?
– If it is a problem of speech production, do most of the problems seem to be related to the sequencing of phonemes?
– If there are no phoneme sequencing errors, what are the characteristics of the patient’s speech errors and any associated motor problems?

Question 37

Stuttering develops and changes over time but in general the development is as follows:

Answer 37

Excessive number of simple repetitions of sounds or syllables, same tempo as other syllables

Then repetitions per word increase and become swifter or irregular

The schwa vowel appears (bc it completely changes the word being spoken)

Next prolongations of sounds occur and then silent articulatory (blocks) postures and then we find evidence of tension and tremors accompanying the repetitions and prolongations

Shortly thereafter, the child demonstrates awareness of his fluency breaks and becomes frustrated…. Then after this, the child begins to show signs of fearing to speak (unfinished sentences (escape), unduly silent, refusing to answer, withdrawn)

When stuttering does occur, he now tries to interrupt it by various devices or explosive struggle resulting in facial contortions, gasping or tongue protrusions

Then after struggle, avoidance devices (synonyms, postponing, interjections, pretending to think) May also see other strategies for timing the speech attempt, such as tapping a finger or leg, using head, finger or leg, head jerk,……

Question 38

Guitar – characterizes normal dysfluency types

Answer 38

Revisions
Interjections
Repetitions (part word, single syllable word, multi-syllabic word, phrase)
Prolongation
Tense pause
….but just because it’s normal, doesn’t mean it’s normal.

Question 39

A Summary of Stuttering Onset and Development

Schwartz

Answer 39

1. The population of persons who stutter is heterogeneous.
2. The speech of children who stutter appears to be different from the speech of normally fluent speakers, right from the onset of stuttering.
3. Stuttering runs in families, although the exact method for genetic transmission remains unknown. It is more common in males.
4. Stuttering onset may be gradual or sudden.
5. Stuttering is a disorder of children with the largest onset occurring prior to age 5.
6. Stuttering often begins as sound/syllable repetitions although some children clearly produce (in)audible sound prolongations at stuttering onset.
7. Nonspeech Associated Behaviors (secondary characteristics) are often present from stuttering onset.
8. A large percentage of children (between 70% - 80%) spontaneously recover from the problem.
9. The greatest amount of recovery occurs within 1 year post stuttering onset.
10. Early stuttering is often characterized by higher frequencies of stuttering that decline within the first 2 years post onset.
11. Lack of positive change (decrease in frequency) in stuttering by 7 months post stuttering onset suggests the need for evaluation and possible treatment.
12. While sponta
    neous recovery can occur for some children beyond 1-year post onset, intervention is encouraged by 1 year post onset.
13. The development of stuttering occurs as a result of the clients’ speech skills, the communicative environment, and the clients’ awareness of, and reactions to, stuttering and the environment.
14. Stuttering is bidirectional.
15. The relatively fast changes in the state of communicative processes precipitate or cause stuttering. The relatively slow changes in the state of extracommunicative processes (e.g. psychological excitement, temperament) tend to aggravate, exacerbate, or maintain stuttering.
16. Certain conditions will make stuttering decrease, at least temporarily.
17. The power of suggestion, as with the treatment of most human problems, is very much involved with the treatment of stuttering.

Question 40

Why do we assess fluency?

Answer 40

to determine whether the client has a fluency disorder or is at risk for developing one
to determine the type of fluency disorder
to identify the set of behaviors that define the client’s fluency problem
to assess the severity of the problem for funding eligibility, litigation and other purposes

Question 41

Conditions that often reduce stuttering

Answer 41

speaking in a nonhabitual manner
reading in chorus (if reading something simultaneously, you don’t stutter if you typically stutter & vice versa)
shadowing or delayed-auditory-feedback (DAF)
singing
using a metronome or pacer
speaking in the presence of loud masking noise
reducing speaking rate
speaking while alone, with children or with animals
speaking in a monotone
trying to stutter
not thinking about or attending to stuttering
playing a role

Question 42

Conditions that often increase stuttering

Answer 42

speaking on the telephone
saying one’s name
telling jokes
repeating a misunderstood message
waiting to speak
speaking to authority figures
speaking to relatively large audience
failing to bring stuttering out in the open
desiring to avoid stuttering
experiencing positive emotional arousal (excitement about birthday)

Question 43

Criteria for diagnosing stuttering - probably stuttering if

Answer 43

total percent of syllables stuttered is 5% or greater
duration of dysfluencies is1 second or longer (you might see 2 seconds in some literature)
presence of associated motor behaviors
client or caregiver’s degree of concern

Question 44

When trying to determine whether or not to enroll, consider the following:

Answer 44

length of time of stuttering
age at evaluation (<4 years old often means much greater chance of recovery without treatment)
child’s reaction
parent’s reaction
prolongations evident or obvious
family history (aunt, uncle, sibling, etc. stuttering; anyone recover from stuttering?)
concomitant disorders
stuttering severity hx (usually but not always but often the more severe, the less likely recovery)

Question 45

Positive prognosis for adolescents, adults, and senior adults

Answer 45

No record of unsuccessful treatment
A cooperative and supportive family system
Cooperative interdisciplinary team members
More severe stuttering pattern (more motivated?)
No other significant, concomitant problems
Other available resources (and interests, hobbies, etc.)
Positive pretreatment motivation and attitude
Significant timing and voluntary enrollment
Commitment to a jointly determined treatment plan and schedule
Personality variables
Positive, yet realistic expectations regarding the commitment required for fluency intervention
Clinician’s attitudes and expectations
Providing information (written report, cover letters, etc.)

Question 46

How to obtain speech samples?

Answer 46

play, role play, simulations

Question 47

Tools to have during stuttering eval:

Answer 47

Video/audio recorder, stopwatch/timer

Question 48

How is stuttering treated?

Answer 48

Thinking about the class definition (developmental, unknown origin, person feels different, overt & covert characteristics), which can be treated?

Question 49

Fluency goals have to consider several things -
Dimensions of fluency

Answer 49

continuity - smoothness
rate - rapid
rhythm - stress patterns
effort - physical and mental

Question 50

Fluency goals have to consider several things -
Speech Naturalness

Answer 50

we don’t want our clients to sound like they have had therapy

Question 51

Fluency goals have to consider several things -
Effective Communication

Answer 51

getting the message out whenever, wherever and to whomever

Question 52

Types of Fluency

Answer 52

spontaneous fluency - the fluency of normal speakers
controlled fluency - the fluency achieved by PWS by monitoring and changing behavior
acceptable stuttering - speech produced PWS but without their negative reactions to it

Attention to feelings and attitudes

   Maintenance procedure

Question 53

Consider Stutter Modification (SMT)

Answer 53

hides or disguises his/her stuttering
avoids speaking
perceives personal penalty as a consequence of stuttering
feels poorly about himself/herself as a communicator
demonstrates a more positive response to stuttering modification trial management

Question 54

Consider Fluency Shaping (FST)

Answer 54

Consider FST when the person who stutters:
stutters openly
does not avoid speaking
perceives annoyance or interference but no personal penalty from stuttering
feels positive about himself/herself as a communicator
demonstrates a positive response to fluency shaping trial management

Question 55

Hybrid Approach

Answer 55

stutters openly, but may demonstrate some avoidance
perceives some sense of personal penalty and negative feelings from stuttering, but
not to an extreme or handicapping degree
feels relatively positive about himself/herself as a communicator, but wishes for
personal change
demonstrates a positive response both to stuttering modification and fluency shaping
trial management

Question 56

Premise

Answer 56

SM: Stuttering results from avoiding or struggling with dysfluencies, fears, and negative attitudes.

FS: Stuttering is learned.

Question 57

Behavioral Treatment Goals

Answer 57

SM: In decreasing order of desirability, goals include spontaneous fluency, controlled fluency, or acceptable stuttering.

FS: Only spontaneous or controlled fluency are acceptable goals. Any evidence of noticeable stuttering is regarded as a program failure.

Question 58

Affective Treatment Goals

Answer 58

SM: Fears and avoidances related to stuttering are reduced by identifying, studying, and understanding thoughts, feelings, and attitudes about communication and oneself as a communicator. Positive social and vocational adjustments are targeted directly.

FS: No attempt is made to reduce communication-related fears and avoidances or impact the attitudes of the person who stutters. As a result of improved fluency, however, fears often reduce and positive social and vocational adjustments occur indirectly.

Question 59

Procedures

Answer 59

SM: Much attention is given to reducing speech fears and avoidance behaviors. The client is taught to be more fluent by various techniques to modify stuttering. Fluency is maintained by reduction of fears and avoidance behaviors.

FS: Little attention is given to reduction of speech fears and avoidance behaviors. The client is “programmed” for stutter-free speech via specific contingencies. Fluency is maintained by modifying the manner of speaking and, if necessary, reinstatement of fluency by recycling through the original program.

Question 60

Structure

Answer 60

SM: A less structured format (such as teaching or counseling interaction) is used.

FS: In contrast, the format is highly structured (which is typical of behavioral conditioning and programming).
Note. From Stuttering: An Integration of Contemporary Therapies (pp. 13-23), by Guitar and T.J. Peters, 1980, Memphis, TN: Stuttering Foundation of America.

Question 61

General Treatment Goals

Answer 61

reduce the frequency of stuttering
reduce the abnormality of stuttering
reduce negative feelings about stuttering and about speaking
reduce negative thoughts and attitudes about stuttering and about speaking
reduce avoidance
increase overall communication abilities
create environment that facilitates fluency
increase the freedom to speak

Question 62

General Treatment Procedures

Answer 62

help clients deal with emotions
reduce the frequency of stuttering
reduce the abnormality of stuttering
reduce negative thoughts and attitudes about stuttering and speaking
reduce avoidance
increase overall communication abilities
create an environment that facilitates fluency
engage motor learning principles

Question 63

Van Riper’s Traditional Approach to Stuttering Modification

Answer 63

MIDVAS:
MOTIVATION - The person who stutters needs to assess her/his motivation for seeking therapy and the SLP needs to help the person build and maintain the motivation necessary for successfully changing speech behaviors and attitudes. Facing one’s weaknesses squarely enough and long enough to change them is not easy for humans to do. Therapy for stuttering is not something to enter into lightly; it takes a large investment of time, physical energy, emotional energy, and money. Motivation gets addressed throughout therapy.

IDENTIFICATION - The client and clinician identify all of the behaviors, feelings, and attitudes that go along with the person’s stuttering. This is like picking the stuttering apart. They identify the core stuttering behaviors, any secondary behaviors, physiological components, such as changes in heart rate, feelings of fear, anxiety, shame, guilt and hostility, and avoidances. Identification can be very difficult for people who stutter because it exposes their shame and feelings of inadequacy. Motivation can appear to change (most likely decrease) during this stage.

DESENSITIZATION - The person who stutters moves into the desensitization stage. Van Riper designed this stage to help drain away the negative emotions, the fears, and the anxieties associated with the act of stuttering. These negative emotions give stuttering its power over the individual. In order for the individual to have control over the stuttering, he or she must drain away these emotions from the act of stuttering so that stuttering becomes a neutral event, sort of a “no big deal.” The most common strategy used in the desensitization phase is called voluntary stuttering, in which the person stutters on purpose. By choosing when and how to stutter, the individual begins to gain control over the stuttering and the fear and anxiety begin to diminish.

VARIATION - Once some of the negative emotions have been removed from the act of stuttering, the individual can change not only how he or she stutter but change his or her reactions to the stuttering. Actual work on changing stuttering behaviors does not happen until the fourth stage of therapy because much groundwork needs to get done first. Many PWS find the initial tasks (or targets) more difficulty than they had anticipated and drop out of therapy before reaching this stage. Much of the person’s behaviors and reactions become ingrained to the point of being stereotyped. The same stimulus (e.g. ringing telephone) will set off the same chain reaction of feelings and behaviors in the person. Varying these stereotyped responses weakens their power over the individual and helps the individual continue gaining control over the fears and the stuttering. Van Riper suggested having individuals change their reactions to word fears, situation fears, communicative stresses, and frustration and penalty. In addition, the individual learns how to stutter differently in this phase. For example, if the person usually prolongs the initial “s” in “sister,” have him or her repeat the sound or stutter on a different sound in the word.

APPROXIMATION - Once the stereotyped pattern of the stuttering has been ‘conquered’, the individual can learn specific strategies to smooth out and minimize the moments of stuttering. The three most common strategies for altering the stuttering are:
cancellation: in which the person stutters all the way through a word, stops immediately, and then repeats the word stuttering a different way
pull-out: in which the person gains control over a moment of stuttering while it is happening and smooths it out
preparatory set: in which the person prepares for a moment of stuttering before it happens, starts it gently and glides through it smoothly.

STABILIZATION - After successfully moving through the previous phases of therapy (with the close guidance of a clinician), the PWS should become his or her own clinician. In the stabilization phase, the individual uses the new stuttering controls in more and more situations of daily life. The individual also continues to stutter voluntarily and to seek out communication situations that he or she previously avoided.

Question 64

Borderline Stage

Answer 64

Approx. Age: 2-3.5
Characteristics: Speech may be characterized by multiple part-word and single syllable whole word repetitions. There is little to no tension or awareness.

Suggested Approach:Fluency Shaping:
Indirect
Use pauses, reduce Q’s and make more comments; have dedicated listening time–first thing in the morning.

Question 65

Beginning Stage

Answer 65

Approx. Age: 2.5-6
Characteristics: The child may have been stuttering for several months. The common stuttering behaviors may be part-word repetitions that are produced rapidly, often with irregular rhythm. Some prolongations maybe present. There may be excessive tension. Blocks may be present. Secondary behaviors are typically escape devices such as eye blinks and head nods. Avoidance maneuvers such as starting sentences with extra sounds like “uh” or changing words when a stutter is anticipated may be observed. Frustration may be present but not typically a strong fear of talking.

Suggested Approach: Fluency Shaping
but you will likely infuse some
Stuttering Modification

SLP – Indirect
Parent – Direct

Parents are w/ child more often, to generalize to everyday life;

Question 66

Intermediate Stage

Answer 66

Approx. Age: 6-13
Characteristics: The stuttering characteristics maybe tense part-word and monosyllabic whole word repetitions, tense prolongations; some blocks with tension and struggle may be evident. The child may use escape behaviors such as body movements or brief verbalizations (e.g. interjections) to break free of stutters. He may also use various avoidance strategies such as starters, word substitutions, circumlocutions, and evasion of difficulty speaking situations. He experiences more frustration and embarrassment than beginning stutterers do and has distinct anticipation of stuttering on specific sounds, words, and many speaking situations, his major fear is the moment of stuttering and he has a definite concept of himself as a stutterer.

Suggested Approach: Stuttering Modification
but you will likely infuse some
Fluency Shaping

Direct

Question 67

Advanced

Answer 67

Approx. Age: Adolescents to Adults
Characteristics: Characteristics at this stage are typically well entrenched and consist of blocks, repetitions, and prolongations that are usually accompanied by tension and struggle. Typically, these individuals have developed negative anticipations about speaking situations and listener reactions.

Suggested Approach: Stuttering Modification

Direct

Question 68

more likely to be neurogenic dysfluency if…

Answer 68

onset after age 10 or 11
an event occurred immediately before the onset of the disorder resulting in damage to CNS
few if any situations in which client is completely fluent (like reading in unison)
client is aware and concerned
repetitions and prolongations occur on final as well as initial and medial syllables
phonemic foci of disfluency may differ from (developmental) stuttering
dysfluency is not related to grammatical function
no direct relationship between linguistic complexity and dysfluency (self-formulated speech may be easier than automatic speech)
the adaption effect is not observed (fluency does not improve with repeated readings)
the speaker may be annoyed but does not appear anxious
secondary features are not always observed

Question 69

more likely to be psychogenic dysfluency if..

Answer 69

onset after age 10 or 11
no event occurred immediately prior to the onset of the disorder that could have resulted in damage to CNS
onset is sudden; an event occurred immediately before the onset of the disorder that could have resulted in severe psychological trauma
few if any situations in which client is completely fluent (affected little by choral
reading, white noise, DAF, singing or different speaking contexts)
client is aware but not overly concerned; indifference
secondary symptoms are not observed
dysfluency is primarily repetition of initial or stressed syllables

    	May also see this referred to as Conversion Speech Disorder

Question 70

Motor speech impact

Answer 70

a) spastic dysarthria: tension may be too great at the beginning of an utterance. Shallow respiration can affect motor control.

b) athetoid dysarthria: involuntary movements of the larynx or tongue can cause dysfluency.

c) chorea-like dysarthria: rapid, jerky movements of the articulators may not allow normal
fluency.

d) flaccid dysarthria: slow, labored speech; muscles tire easily and fluency deteriorates.

e) ataxic dysarthria: muscle tone is reduced and incoordination of the articulators can take
place.

Question 71

Dysfluency associated with apraxia

Answer 71

struggle to produce speech and thus may sound like PWS when their fluency
breaks down.
know what they want to say, but cannot execute the appropriate movements
necessary to produce the target utterance.

The flow of speech and normal intonation patterns are affected, and since these individuals
are aware of their problem, they struggle to correct errors and generally become very
disfluent with a lot of whole word and phrase repetitions.

Question 72

Dysfluency associated with aphasia

Answer 72

Confusion of ideas will frequently lead to speech characterized by hesitations, whole word
repetitions, revisions and filled and unfilled pauses.
Word retrieval deficits will also result in long pauses and word/phrase repetitions as well.
The most common site of lesion in aphasics with fluency deficits are caused by frontal lesions
associated with stroke or brain trauma.

Question 73

Assessment

Answer 73

1) Standardized Tests:
a) Aphasia Diagnostic Profiles
b) Boston Naming test

2) Standard Speech Passages (repeated readings):
a) “The Rainbow Passage”
b) “The Grandfather Passage”

3) Automatic Recitations:
a) Counting to 30
b) Months of the Year
c) “The Pledge of Allegiance”

4) Singing Familiar Songs

Question 74

Psychogenic Disfluency
Evaluation should include:

Answer 74

case history – include setting and perspective; ask about events that may have occurred
history and current pattern of disfluency
motor speech exam
evaluation across multiple speaking contexts
stimulability or trial therapy
Consult with other service providers for the client.

Question 75

In some settings, Malingering may be considered a type of psychogenic disfluency.

Answer 75

Malingering is faking a disorder to receive some benefit. Malingering has been reported in criminal cases and civil lawsuits.
Assessment – complete a fluency assessment as usual including case history, screenings and stuttering evaluation (including procedures and analysis). In the analysis, use the information from table 15.3 to help distinguish what you’re seeing and hearing from stuttering (or psychogenic or neurogenic disfluency).

Question 76

Cluttering

Answer 76

is a fluency disorder characterized by a rapid and/or irregular speaking rate, excessive dysfluencies, and often other symptoms such as language or phonological errors and attention deficits. To identify cluttering, you must listen to nonstuttered speech of the speaker. Evidence for a fluency disorder (one that is not stuttering) and excessive dysfluencies, would be present in a speaker who meets all of the following:
Does not sound “fluent,” that is, does not seem to be clear about what he or she wants to say or how to say it.
Has excessive levels of “normal dysfluencies,” such as interjections and revisions.
Has little or no apparent physical struggle in speaking.
Has few if any accessory (secondary) behaviors.
A rapid and/or irregular speaking rate would be present in a speaker who has any or all of the following:
Talks “too fast” based on an overall impression or actual syllable per minute counts.
Sounds “jerky.”
Has pauses that are too short, too long, or improperly placed.
These fluency and rate deviations are the essential symptoms of cluttering. In addition, however, there are a number of symptoms suggested in the latter part of the above definition that may or may not be present but add support to the impression that a person is cluttering. Accordingly, the clinical picture of a typical cluttering problem would be enhanced if the person in question had any of the following:
Confusing, disorganized language or conversational skills.
Limited awareness of his or her fluency and rate problems.
Temporary improvement when asked to “slow down” or “pay attention” to speech (or when being tape recorded).
Mispronunciation or slurrring of speech sounds or deleting non-stressed syllables in longer words (e.g., “ferchly” for “fortunately”).
Speech that is difficult to understand.
Several blood relatives who stutter or clutter.
Social or vocational problems resulting from cluttering symptoms.
Learning disability not related to reduced intelligence.
Sloppy handwriting.
Distractibility, hyperactivity, or a limited attention span.
Auditory perceptual difficulties.

Question 77

Cluttering assessment

Answer 77

should include different tasks to include oral reading, spontaneous speech, retelling a memorized story, a test of oral motor coordination and questionnaires. Cluttering severity may vary depending on the nature of the speaking task. Cluttering behaviors are more likely to surface as the speaking task is more extemporaneous and informal, less structured, more emotional, and linguistically more complex.

Question 78

Cluttering Assessment: Oral Reading

Answer 78

The nature of the oral reading task will limit the possibilities for language formulation difficulties in the clutterer; however, omission of syllables and words (particularly pronouns and articles) may occur. Take note of errors in syllable and word structure such as telescoping of syllables or semantic paraphasias. Because the level of reading material may influence degree of cluttering, present clients with appropriate reading material that vary in reading difficulty. The more difficult passages, containing more multisyllabic words and linguistically more complex sentences, may produce more cluttering behaviors compared to the less difficult passages. It is also suggested that the client read a passage with and one without preparation, to compare the results of the prepared and unprepared reading.

Question 79

Cluttering Assessment: Spontaneous Speech

Answer 79

Engage the client in a more relaxed exchange on a subject that is of high interest to the client. This can include explaining a videogame, telling about his favorite sport or leisure activity, or telling a story about a recent exciting event that the client experienced. Record at least 10 minutes of of this language sample. The language sample should consist of a narrative rather than iterations of events as in a list. We have found that cluttering behaviors become more evident the more informal, spontaneous and extensive the talk. When the client is not aware of the recording you will have the highest chance of recording “uncontrolled” cluttering speech. Such speech may also be observed when recording the interaction between, for instance, the parent and the child, or the adult and partner while you leave the room for a while.

Question 80

Cluttering Assessment: Articulation

Answer 80

Assessment of articulation should include tasks that range from short and structured tasks, to longer and less structured tasks. Examples of the former include rote tasks such as counting or reciting memorized material. Be aware of errors in syllable- and word structure and take measures of articulatory rate. Some clutterers have phoneme-specific misarticulations. Most clutterers exhibit reduced (non-phoneme-specific) speech intelligibility as the talk becomes more informal and extended. Speech intelligibility arises from elisions of sounds and syllables, neutralization of vowels, cluster reductions.
Ask the client to count backwards: 100-97-94-91….
Ask the client to count from 20 to 29
Older clutterers should read some words that are difficult to pronounce (e.g., “statistical,” “chrysanthemum,” “possibilities,” “tyrannosaurus”) and produce these words three times in succession first at their comfortable rate and then at a faster speech rate.
Older clutterers should read some words with changing stress pattern sequences such as “apply, application, applicable” (a_ply’ / a_pli_ca’_tion / a_pli’_ca_ble).
OMAS (Riley and Riley, 1985): Although the norms for adolescents and adults are lacking, the diadochokinetic tasks of the oral motor assessment scale (OMAS) provide clear guidelines for observation of oral motor coordination.
Imitation of numbers (forward and backward) provides information of auditory memory and flexibility.

Question 81

Cluttering Assessment: Language

Answer 81

People who clutter commonly experience language deficits besides their articulatory problems. It is, therefore, important to assess the language skills of the client. Language difficulties include word-finding problems, poor syntactic structure, lack of coherence and cohesion in discourse and narratives, and compromised pragmatics (e.g., poor presuppositional skills such as not taking into account the listener’s viewpoint or knowledge; frequent interruption of conversational partner’s turn) in individuals who clutter. We speculate that a number of the clutterer’s disfluencies are motivated by linguistic rather than motoric difficulties; these disfluencies are often called “linguistic maze” behaviors.
Ask the client to retell a story you told them. Observe the following as the client retells you the story: ability to paraphrase the story with the major points of the narrative in logical sequence, and with intact story grammar, maintaining syllable-, word- and sentence structure, appropriate pausing, adequate speech intelligibility, appropriate pragmatics.
Imitation of sentences of increasing length (up to 20 word-sentences) for adults and adolescents. This task provides information on auditory memory skills and on the amount of language complexity the client can handle.

Question 82

Self-Assessment
Cluttering checklists and self-assessment

Answer 82

Predictive Cluttering Inventory (Daly and Cantrell, 2006), also translated in Dutch (by van Zaalen, 2007) and in German (by Abbink, 2007).
Checklist of Cluttering Behaviours (Ward, 2006)
The Perceptions of Stuttering Inventory (Woolfe, 1967)
WASSP (Wright and Ayre, 2000)
The S-24 (Andrews and Cutler, 1974)
Where there are questions relating to cluttering behaviors (for example, some questions on the WASSP and PSI relate to the physical aspects of disfluencies), comparisons can be made between the clinician’s observations and those of the client. For instruments tapping feelings and attitudes (such as the S-24, subsections of the WASSP and the “expectancy“ and “avoidance” statements on the PSI), the clinician can go through the responses together with the client once the client has completed the assessment and use the client’s responses as springboard for subsequent therapy.
Ask the client to critique his own speech during various recorded tasks, compared to the clinician’s critique. A 5-point rating scale is often useful to judge the recorded samples on each of the major dimensions of the client’s speech and language.

Question 83

Differential diagnostics with other disorders

Answer 83

Cluttering usually co-exists with other disorders such as stuttering, articulation disorders, attention-deficit disorders/hyperactivity disorders and learning disabilities.
The available literature as a whole suggests that an essential difference between cluttering and stuttering lies on the speaker’s level of preparedness for saying intended utterances. Stutterers know what they intend to say but are interfered at the motoric level in their attempts to produce various words, whereas clutterers do not necessarily know all of what they want to say (or how to say it) but continue talking anyway. Part-word repetitions, prolongations and blocks are typically produced by stutterers, whereas excessive but normal disfluencies often characterize the speech of clutterers. The latter include interjections, incomplete phrases/words, revisions.
Persons who clutter exceed the normal qualitative and quantitative limits of changes in phonemes and tend to delete or neutralize syllables that standard speakers do not neutralize, especially in fast speech. Although symptoms of ADD/ADHD are mentioned as cluttering, individuals diagnosed with ADHD do not necessarily clutter.
Specific Learning Difficulties have been reported to co-exist with cluttering, especially difficulties in oral expression, reading, writing, handwriting and music; however, corroborating data for these observations are anecdotal.

Question 84

Treatment for Neurogenic dysfluency

Answer 84

Rate reduction
Rhythm (such as MIT)
Prolongation

During a conversation, baselines of target behaviors are obtained for comparison in Step 4.

Step 1. To help the patient learn to self-monitor, the patient should listen to audio-recordings of his/her own speech while the SLP points out instances of the target behavior to them.

Step 2. Patients listen to audio-recordings of their speech and use a counter to monitor the target behavior. If there is no signal within 3 seconds of the occurrence of the behavior, the SLP stops the tape and identifies the behavior.

Step 3. Patients self-monitor during a speaking task (like describing a picture). Repeat strategy for identification used in Step 2.

Step 4. Patients self-monitor while performing the speaking task used in Step 3 but without SLP feedback and reinforcement. Compared to baseline data.

Compare their needs to that of a person diagnosed with aphasia or a motor speech disorder like dysarthria. Use appropriate evidence-based strategies from those clinical areas.

Question 85

Treatment for Psychogenic dysfluency
Guitar (2006)

Answer 85

Person shows good signs of psychological adjustment; can decrease stuttering in trial tx?
good candidate for tx so start speech services right away

Person is unable to decrease stuttering in trial tx or continues to have some indications of dysfunction? good candidate for tx if it’s provided in conjunction with psychotherapy

Person is unable to decrease stuttering in trial tx or denies that the stuttering might be stress related?
poor candidate for tx (perhaps extended treatment might be considered)

Once it’s determined that therapy is appropriate, fluency shaping strategies have been effective. Those include:
● light contact
● easy onset
● easy repetitions

Techniques from Duffy (2005) that address what he calls ‘symptomatic therapy’

1. Identify for the patient the behaviors that represent the disorder (eg. tight and effortful voice, whispering, facial grimacing, neck extension; eye blinking, etc.)
2. After the behaviors are identified, tell the patient that they reflect a well-intentioned effort to speak but are actually physically exhausting and acting as a barrier to more normal speech.
3. Have the patient do something with speech that approximates a normal or at least different response. This can range from a grunt to a sigh to a prolonged sound to a single syllable.
4. Talk to the patient about what has and is going on during symptomatic efforts.
5. Laryngeal manipulation and massage can be effective in reducing tension. Touch can be a valuable
   tool both physically and psychologically.
6. With improvement, it is appropriate to accelerate enthusiasm about the patient’s progress. Gradually
   begin to withdraw touch with expectations that the patient can modify speech without physical assistance.
7. With continued improvement, ask patients to read a paragraph and get a feel for the their improved speech. The SLP can interrupt to ask some general questions; the patient’s improved speech during such responses should be noted.

Duffy (2005) provides guidelines for addressing services beyond the steps listed. Those include how to handle it if the speech problems return, don’t resolve, or if they continue to do well (in or out of the presence of the contributing psychogenic issue).

Question 86

Treatment for Malingering

Answer 86

It’s not typically treated; the SLP may work with others (psychiatrists, law enforcement, social workers, attorneys, etc) to help identify malingerers. Should the person’s malingering manifest secondary to a larger psychiatric or emotional challenge, the SLP may be called upon to consult with those professionals in patient support.

Question 87

Assessment of Fluency (After the case history, oral mech, and hearing screening)

Answer 87

Procedures
· administer a standardized test (all employers will not require)
· obtain speaking samples from at least 3 or 4 contexts
· assess feelings, emotions, attitudes, reactions MAY BE CONSIDERED INCOMPLETE IF OMITTED
· observe/document any secondary characteristics or physiological factors
· screen language, voice, and articulation
· assess stimulability
Analysis
· frequency of stuttering per stuttered syllables

· pattern of dysfluencies (types, like blocks, ect…)

· duration of the longest stuttering moments

· impact of secondary behaviors

· severity rating

· rate of speech (words or syllables per minute)

Question 88

Fluency goals should consider several things -

Answer 88

Dimensions of fluency

          	Speech Naturalness
 
          	Effective Communication
 
          	Types of Fluency
                	spontaneous fluency - the fluency of normal speakers
                	controlled fluency - the fluency achieved by PWS by monitoring and changing behavior (FST)
                	acceptable stuttering - speech produced PWS but without their negative reactions to it (SMT)
 
          	Attention to feelings and attitudes
             
          	Maintenance procedures

Question 89

Treatment, like other aspects of our profession, can be summarized with an acronym:
PROLAM

Answer 89

Physiological adjustments
Rate reduction
Operant conditioning
Length and complexity of utterance
Attitude adjustments
Maintenance, movement, and monitoring

Question 90

To Increase Awareness and Self-Monitoring Skills

Answer 90

Use audio and video recordings of speech to monitor and self-correct.
● Record client’s speech and play it back: (1) at a fast speed to show how cluttering sounds; and (2) at a slow speed to show how it might be improved (reorder wherein these functions preserve the vocal frequency).
● Heighten client’s sensory awareness of movement first during nonspeech motor acts such as rate of moving arms or hands or when walking, then during speech motor acts.
● Use various types of computer-generated visual feedback of speech rate (e.g. comparing client’s tracing with clinician’s model on a Visi-Pitch screen
● Give “speeding tickets” (for children) following episodes of rapid speech.
● Use feedback from listener (e.g. facial expressions, verbal indications of communication breakdown due to clutterer’s poor speech, and linguistic coherence).
● Provide opportunities to monitor and provide feedback to other clutterers in group sessions.

Question 91

To Improve Rate (as well as Articulation and Speech Intelligibility)

Answer 91

Slow overall rate using delayed auditory feedback (DAF).
● Use syllable-timed speech (e.g., metronome) as an intermediary technique (this approach alone would not facilitate natural sounding speech.)
● Prolong vowels because they are easy focal points to prolong, thereby reducing rate.
● Attend to word endings and unstressed vowels and syllables.
● Use more distinct and more deliberate articulatory gestures (e.g., wide excursion of articulators).
● Impose pauses for breath groups.
● Mark reading passages with “stop signs” wherever there are periods and commas.
● Use analogy of speedometer to regulate rate.
● Use self-imposed phrasing to help with organization of speech and language or though.
● Aim for greater prosodic variations (assuming that greater prosodic variations will slow the rate and produce more natural-sounding speech).
● Give added stress to accented syllables.
● Read and/or recite poetry with “interpretation” to increase prosodic variations and pauses and to increase overall effectiveness of speech delivery.
● Use skits and plays to: (1) increase awareness of partner’s turn in conversation; and (2) highlight pauses imposed by lines from different speakers to automatically stop the clutterer from perseverating and festinating (i.e., going faster and faster).
● Use music to impose slower and/or more varied prosody (e.g., smooth, easy, and slow lullabies vs fast staccato beat of a march).
● If group therapy, have clients take turns “conducing” speech and/or singing depending on their “composition” (legato, allegro, pianissimo); have children sing or recite a lullaby for softer, gentler , slower speech or a march for more rhythmic and deliberate cadence.
● Shadow the speech of slow and effective speakers.

Question 92

To Improve Linguistics and Narrative Skills

Answer 92

Teach clients elements of story grammar (i.e., episodes, problem resolution).
● Help clients to sequence thoughts if they report several thoughts coming at once.
● Increase turn-taking skills to reduce tendency to interrupt and improve skills for appropriate adjacency and contingency.
● Increase semantic classification and categorization skills for word-finding difficulties.
● Increase speed and accuracy of word retrieval (e.g., naming drills).
● Formulate ideas using appropriate syntactic structures.
● Increase cohesion of extended talk (e.g., through appropriate use of relational terms such as “although” and “however”).

Question 93

To Improve Fluency Skills

Answer 93

● Review audio and video recordings for use of fillers, revisions, incomplete phrases, and other disfluencies.
● Have client transcribe his or her own maze behaviors (e.g., use the systematic disfluency analysis (SDA) [Campbell & Hill, 1994] system and point out inefficiencies in clients information output due to excessive maze behaviors).
● Use aforementioned strategies for rate and language to decrease disfluencies as well.

Question 94

To Improve Meta-Cluttering Skills

Answer 94

● Point out specific attributes of client’s cluttering behaviors (e.g., difficult to understand, dropping of sounds and syllables).
● Differentiate reactions of self and others to the client’s cluttering.
● Compare the nature of thought and language organization after moments of clarity with moments of incoherence.
● Compare sensory feedback associated with fast rate, irregular rate, and slower rate.
● Discuss with client the relative effectiveness of different therapy approaches.
● For clutterers who also stutter, talk about behaviors associated with one’s moments of cluttering compared with stuttering.
● Identify effects of speaking rapidly on general body state (e.g., “Do you feel more tense when you talk fast?”).
● Compare effects on clutterer when others speak rapidly versus more slowly.
● Explore jointly client’s reactions when speaking to someone who is difficult to follow because of poor speech intelligibility or poor narrative and pragmatic skills.
● Use analogies from animal kingdom (e.g., stride of a racehorse vs hippopotamus or penguin) or engines (e.g., car skidding on ice, derailment of speeding train, or the synergism of a Porsche engine).

Question 95

To improve Phonatory and Respiratory Behaviors

Answer 95

● Mark passages with pauses for breath intake.
● Heighten client’s awareness when exceeding optimum number of words per breath group.

Question 96

To Improve Family, Friend, and Employer Support

Answer 96

● Obtain feedback, during moments of clear speech and poor communication, from family and friends.
● Recommend participation in group speaking activities (e.g., oral presentations at school, Toast-master ([www.toastmasters.org]), or other monitored activities at home or school).

Question 97

To Improve Collaboration with Other Team Members

Answer 97

● Consult with-or refer to-ECE specialist if school-age clutterers have significant attention, activity, distractibility, or academic problems; coordinate treatment plans around other ECE goals if relevant.
● Consult with-or refer to-psychologist if adult clutterers have significant problems (e.g. ADHD).
● Consult with –or refer to- mental health specialist if clutterers manifest problems in social adjustment.
● Consult with-or refer to-pediatric or general neurologist if clutterers have pharmacological issues.

Question 98

To Foster Transfer and Maintenance

Answer 98

It is one matter to help the clutterer become a slower, more fluent, and more intelligible speak while speaking in an ideal situation such as with the clinician. It is quite another for the person to make those changes permanent in all communicative situations. To foster transfer and/or maintenance, the clinician should program specific activities and assignment designed specifically for each client’s needs. Following are a few suggestions that may assist in this process.
Daly (1992) outlined a procedure for preparing “anchor” recordings for clients - short samples of the person’s seriously cluttered speech, slightly clutterered speech, and noncluttered speech are recorded. The client is asked to listen to the tape every day or even several times a day, to:
● help maintain awareness of what goes wrong in cluttering
● serve to “recalibrate” the targets of good speech
● provide consistent reminders to practice.
Whether or not “anchor” recordings are used, activities to promise daily speaking practice in a new and controlled way can be useful. Some clutterers have found that self-help groups for stuttering, such as National Stuttering Association chapters, are good places to practice and feel the support of others. It is likely that clutterers who might benefit from attending a stuttering support group will need to educate the group members about cluttering and how its treatment and maintenance challenges may be different from those faced by those who stutter.