Stuttering Flashcards
Stuttering is a
Neurodevelopmental disorder characterized by a disruption in the transition between sounds, syllables, and words
What causes stuttering?
Stuttering is multifactorial (i.e., a result of constitutional, developmental, and environmental factors)
Constitutional: age, gender, family history
Developmental: emotion, language, executive functions
Environmental: maternal use of alcohol/drugs, low birthweight, social environment, stress level
Examples of stressful adult speech models
- Rapid speech rate
- Complex syntax
- Polysyllabic vocabulary
Examples of stressful speaking situations & life events for children
Speaking situations:
- competition for speaking
- frequent interruptions
- rushed when speaking
- frequent questions
Life events:
- Moving
- Divorce
- Family death
- Holiday/change in schedule
When does stuttering onset typically occur? What does it coincide with?
Between 2-4 years of age
Coincides with a boost in language development (increased use of various speech sounds, complex utterances)
What does stuttering co-occur with?
- Phonological delay
- ADHD/ADD
What is spontaneous recovery? When is the probably of recovery highest? When does most children recover?
Recovery from stuttering without treatment - a gradual & steady decrease in sound, syllable, and word repetitions and prolonged sounds over time
Probability of recovery is highest 6-12 months post-onset
Majority of children recover 12-24 months post-onset
Provide 6 risk factors for chronic stuttering
- Older at onset
- Male
- Family history
- Higher freq. of stuttered disfluencies
- Lower speech sound accuracy
- Lower expressive and receptive lang. skills
What is the diagnostic criteria for stuttering?
- Speaker produces ≥ 3% freq. stuttered disfluencies in a representative conversational speech sample
- Parents/caregivers express concern
What are some breathing abnormalities associated with stuttering?
- Speaking on inhalation
- Holding breath before talking
- Rapid and jerky breathing
Examples of negative emotions associated with stuttering
- Anxiety
- Fear of speaking
- Frustration
- Humiliation
- Avoidance
Provide examples of secondary behaviors associated with stuttering (motor and hidden)
Motor:
- Excessive muscular effort
- Facial grimaces
- Rapid eye blinking
- Tongue clicking
Hidden:
- Avoidance/circumlocution
- Fatigue
Loci of stuttering
The location in a speech sequence where stuttering is typically observed:
- Consonants
- First sound/word
- Longer & content words
- Less frequently used words
Define neurogenic stuttering
Stuttering caused by a neurological disease, brain damage, or pharmacological agents
Features of neurogenic stuttering
- Stutters occur equally on function & content words AND in all positions of words
- Little or no adaptation on repeated readings of a passage
- No secondary behaviors
- Relatively little fear/anxiety when speaking
Define cluttering
Sudden bursts of rapid speech that are difficult to understand
Features of cluttering
- Fast speaking rate
- Excessive normal disfluencies
- Lack of self-monitoring
- Slurred speech, omitted syllables, disorganized language
What diagnoses co-occur with cluttering?
- Stuttering
- Articulation disorders
- ADHD
- Learning disabilities
- Auditory processing disorders
What is the CALMS model?
- Cognitive
- Affective
- Linguistic
- Motor
- Social
This model is effective for fluency diagnosis because it provides a well-rounded framework that addresses the psychological, physical, and social dimensions of fluency, leading to more effective assessments and interventions.
CALMS - Assessing the “cognitive” component
- Evaluate the speaker’s thoughts/perceptions: Do they have a negative view of their own stuttering? A negative view on listener reactions?
- Evaluate the speaker’s awareness/understanding: Can they identify moments of stuttering?
CALMS - Assessing the “affective” component in preschool-age children
KiddyCAT: identifies the child’s attitude toward communication and speech
This measure allows SLPs to understand how the child feels about speaking in different social environments and provides information to see if they benefit from additional assessment or targeted intervention.
CALMS - Assessing the “affective” component in school-age children
Communication Attitude Test (CAT): examines how a child perceives their communication difficulties and how it affects their confidence, social interactions, & willingness to engage in communication
CALMS - Assessing the “affective” component in adolescents/adults
Overall Assessment of the Speaker’s Experience of Stuttering (OASES): provides a comprehensive assessment of the stuttering disorder from the speaker’s perspective
Broken into 3 sections
- Affective, behavioral, and cognitive reactions to stuttering
- Difficulties with communication in daily situations
- Impact on QOL
CALMS - Assessing the “linguistic” component
Tools: speech sample, MLU, stocker probe
Stocker probe: questions/requests that progressively increase in cognitive demand (presented using common objects)
CALMS - Assessing the “motor” component
Severity: frequency, type of stutters, duration, secondary behaviors
- Duration: calculate avg of 3 longest stutters
- Secondary behaviors: escape vs avoidance
- Typical speech characteristics (intonation, articulation, loudness, body language, etc.)
Secondary behaviors: escape vs avoidance
Escape: occur after the stutter has started; attempt to stop stutter and produce a word (head nod, eye blink)
Avoidance: occur before stutter has begun; attempt to keep from stuttering (saying extra sound, changing word)
How can you use a speech sample in a stuttering evaluation?
Collect in multiple settings to ensure the sample is representative of the speaker’s current level of stuttering. Assess the speaker’s stuttering using a disfluency count manual. Evaluate their speech and note the types and frequency of stuttered/non-stuttered disfluencies.
What are two standardized measures that are used to diagnose stuttering?
Stuttering Severity Instrument-3 (SSI-3)
- 2;10 years +
- Measures frequency (% syllables stuttered), duration (avg of 3 longest stutters), and secondary behaviors
Test of Childhood Stuttering (TOCS)
- 4-12 years
- Measures speech fluency in different linguistic contexts
- Observation & supplemental clinical assessment
Supplemental testing during a stuttering eval. if the SLP has additional concerns
- Articulation and language assessment
- Cognitive: learning disability, attention deficit, intelligence
- Social-emotional: ability to make friends, anxiety
What should SLP do before creating a treatment plan for preschool-age child?
Review risk factors for persistent stuttering, consult w/caregivers, etc.
Compare and contrast indirect vs direct approaches
Indirect:
- Meant for children 2-4 years old
- Used when children are unaware of speech
- Adjust context in which communication occurs to facilitate fluency
Direct:
- Used when child demonstrates awareness of stuttering (especially if reactions are negative)
- Applicable if indirect approach has not improved fluency
Examples of indirect treatment programs and approaches
- Stuttering Severity Scale
- Online resources for parents
- Educate parents on appropriate speech models
- Family-focused treatment
- Palin parent-child interaction therapy
- Integrated Fluency and Resilience program
What treatment goals are targeted when following and indirect approach?
- Speech/non-speech behaviors of parents
- Spontaneous fluency
- Positive speech attitude
What is family-focused treatment?
- Indirect approach
- Appropriate for children aged 2-6
This approach educates parents on using appropriate communication modalities (e.g., easy talking model, increased pause time, reducing tames, reflecting/rephrasing). Parents are also taught to accept/understand stuttering, identify stressors, and prioritize communication wellness.
Children learn to understand and become accepting of stuttering. This approach also incorporates a direct component, as it includes speech and stuttering modification.
What is Palin parent-child interaction therapy?
- Indirect approach
- Normed for children under 7
During the Palin program, the child and parents attend therapy sessions aimed at improving fluency, confidence, and parental understanding of stuttering. The program begins with a block of clinic sessions, followed by home practice to foster a positive communication environment.
Progress monitoring:
- Stuttering frequency is assessed through video-recorded speech samples.
- Progress regarding the child’s attitude toward speaking is measured using the KiddyCAT
- The parent’s perception of stuttering is measured using the “Palin Parent Rating Scale (PRS).” This scale assesses the parent’s views across 3 parameters - impact on child, severity of stuttering, and parent’s knowledge.
What is the Integrated Fluency and Resilience Program?
- Indirect approach
This 12-week program integrates self-regulation into the treatment approach. Parents are trained in facilitating fluency (e.g., incorporating direct approach to draw attention to stutter using neutral language.)
This program also implements resilience principles with techniques to incorporate in the home environment. Examples of principles include independence, problem-solving, and responsibility.
Progress is assessed using various measures - SRS, logbook, strengths/difficulties questionnaire, etc.
What is The Lidcombe Program?
- Direct approach
- Children younger than 6 years old
Through this program, parents provide “center corrections” for unambiguous stutters approx. 1x every 5 stutters. Clinicians train parents to administer praise/correction during structured and unstructured time at home. Parents and children attend weekly clinic visits starting with structured and transitioning to unstructured sessions. Progress is monitored through daily SRS logs and %SS as measured by the clinician.
What is Westmead?
- Direct program
- Younger than 6 years old
Westmead is parent-administered (must be supervised by SLP) treatment that is delivered in the child’s natural environment. The goal of this tx is for the child to achieve little to no stuttering & natural sounding speech. This approach utilizes syllable-timed speech, or saying each syllable to a beat.
Level I, II, and III Tx
Level I: Turtle speech
- Contrast fast (out of control) vs slow (in control)
Level II:
- Acknowledge that speech can be smooth or bumpy
Level III: Stretch speech
- Implement light articulatory contacts, contrast hard vs soft objects
- Increase level of practice (sounds through sentences)
What are 4 “school-age” child therapy goals?
- Speech behavior: both stuttering and fluent speech
- Fluency: fluent speech, controlled stuttering, acceptable/easy stuttering
- Feelings: reduce negative attitudes
- Clinical methods: fluency shaping and stuttering modification
Affective treatment for school-age children
Children can attend support groups that highlight the value of communicating freely (instead of 100% fluency.) These groups reduce fear/avoidance, allow for practice on feared sounds, and help children find support in others who stutter.
Cognitive treatment for school-age children
It’s valuable to educate children about the nature of speaking and stuttering. This increases their level of awareness and allows them to reflect on what they do when they speak fluently and when they stutter.
Ask the child: Are you aware you stutter? What are your thoughts/beliefs about why you stutter? How do you stutter? What do you do to help?
What are behavioral treatment approaches for school-age children?
Exploring talking
- establish common terminology
- educate child about the coordination of respiration, phonation, articulation
Exploring stuttering
- discuss how the child stutters & explore what “speech helpers” do during speech/stuttering
- this approach is used to desensitize the child to stuttering
Changing talking
- changing rate, soft starts, superfluency
Changing stuttering
- voluntary, holding/tolerating, pullout, cancellation
What are the two “changing talking” approaches?
- Changing rate: Teach the child to use slower speech overall (fewer syllables or words per minute). Strategies include stretching sounds/syllables and strategic phrasing/pausing. This allows them more time to make changes in complex motor movements.
- Soft starts: Slower, relaxed speech initiation allows for decreased muscle tension and less articulatory constriction. Teach the child to initiate smooth airflow/voicing and physically relaxed, smooth articulator movement at the beginning of phrases.
What is super fluency?
A combination of the follow techniques - flexible rate, pausing, easy onset, light contact, proprioception
What are the 4 “changing stuttering” techniques? Explain them.
- Voluntary stuttering: Teach the child to stutter on purpose - starting with unfeared words and progressing to more complex/feared words. This builds awareness of stuttering moments, decreased fear/avoidance, and desensitizes to listener reactions.
- Holding/tolerating: Once they can identify how/when they stutter, teach the child to stay in a moment of stuttering. This increases awareness and is desensitizing.
- Pullout: Once they’ve learned to hold onto a stutter, teach the child “pullout.” This technique emphasizes holding on to a stutter before easing off tension and moving into the next sound. This allows the child to confront a moment of stuttering and release tension. It’s especially helpful when a child experiences high emotionality or is “stuck.”
- Cancellation: In therapy sessions, teach the child finish a stuttered word, pause, and stutter on the word again in an easier way. This discourages avoidance behaviors and reinforces easier stuttering.
What is disclosure?
Teach the child to openly acknowledge their own stuttering to listeners. This allows them to take control, promote openness about using techniques, and inform listeners about their preferences.
What are realistic fluency goals?
- Controlled fluency when it’s important
- Easy stuttering when controlled fluency isn’t available
- Acceptable stuttering when neither can be achieved
What does the Conflict Theory of Stuttering state?
Stuttering is caused by different fears of specific words, speaking situations, fear of failure. This feat stimulate conflict between opposing drives: to speak vs to avoid stuttering and to express oneself vs to avoid exposing oneself.
What is the approach-avoidance model?
This model encourages adults to approach more and avoid less. Adults are motivated to engage socially and communicatively rather than isolate.
Support group vs Therapy group
Support
- Nonprofessional, relating personal experiences, providing sympathetic understanding, establishing social network
Therapy
- Facilitated by qualified professional, EBP, treatment plan w/goals and objectives
What is avoidance reduction therapy?
A stuttering modification approach that aims to modify the moment of stuttering rather than the way a person speaks.
This approach works to reduce avoidance of words/sounds, situations, identifying as a pWS, and feeling shame. It values comfortable, forward moving speech and connecting with others.
What is Cognitive Behavior Therapy?
The cognitive model states that a person’s perception influences emotion and behavior. Oftentimes, the way an individual construes a situation determines how people feel.
Automatic thoughts trigger emotion which typically lead to negative behavior (e.g., excessive tension.) CBT identifies these automatic thoughts, helps the client attach emotions/behavior, and evaluates the validity and utility of the thought.
CBT implements journaling as a way for the client to record automatic thought, observe the outcome, and assess the usefulness of their thoughts.
