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CSD 2230

INTRODUCTION

• Fluent speech is the consistent ability to move the speech production apparatus in an effortless, smooth and rapid manner resulting in a continuous, uninterrupted forward flow of speech.
• Developmental stuttering, or simply "stuttering", primarily influences the speaker's ability to produce fluent speech.
• Stuttered speech is characterized by
  • involuntary repetitions of sounds and syllables (i.e., b-b-b ball)
  • sound prolongations (i.e., mmmmm-mommy)
  • broken words (i.e., b ------ oy).
• The cause of stuttering is unknown.
  • Stuttering affects people worldwide.
  • Physicist Sir Isaac Newton, author W. Somerset Maugham (OfHuman Bondage) and statesman Winston Churchill stuttered, performers James Earle Jones, Carly Simon, Marilyn Monroe, and Bruce Willis stuttered.
  • Stuttering is insensitive to nace, creed, color, intellect, and virtually any other attribute that could be used to distinguish one human being from another.
• Stuttering has a negative effect on a wide variety of daily life activities within three main venues of life, school, work, and social interactions.
• Effects of Stuttering on School Performance
  • Stutterers, on the whole, are poorer in educational adjustment than normal speakers.
  • On average, children who stutter are delayed about one-half year or one-half grade level.

Incidence & Prevalence

• The incidence of stuttering is determined by the number of adults who report that they stuttered at some time in their life: 5%
  • Includes the high percentage of children who spontaneously recover (About 85%i.e., 4 out of 5) from the disorder prior to the age of six, which reducing the actual incidence to to about 1%.
  • Females appear to recover from stuttering more frequently than males.
• The prevalence of stuttering is determined by ascertaining the number of cases in a given population (usually school-age children) during a given period of time.
  • In the United States the average prevalence rate is .97% for school-age children.
  • Stuttering affects more males than females with reported sex ratio differences ranging from 2.3 to to 3. 0 to 1.

Fluent Speech Versus Stuttering

• Children exhibit hesitations, revisions, and interruptions in their utterances.
  • Children are not born as fluent speakers.
  • Children near 25 months of age are more fluent than they will be at 37 months.
  • Fluency improves following third birthday and types of disfluency change.
• Normal Disfluencies
  • 2 years of age, typical disfluencies are:
    • whole word repetitions (I-I-I want a cookie.),
    • interjections (Can we-uhm-go now?)
    • syllable repetitions (I like ba-baseball)
  • 3 years of age - revisions like "He can't --- he won't play baseball" are the dominant.
  • Normal disfluencies persist throughout the course of one's life, but they do not tend to effect the continuous forward flow of speech adversely.
• Stuttered Disfluencies
  • Stuttering or stuttered speech involves:
    • part-word repetitions
    • sound prolongations
    • monosyllabic whole word repetitions
    • within-word pauses.
  • Stuttering is any cessation in the forward flow of speech marked by:
    • audible or inaudible repetitions or prolongations of word/syllable fragments
    • periods of silence between words/syllables
  • Disfluencies that occur within a word unit that are likely to be regarded as stuttering include:
    • monosyllabic whole-word repetitions (i.e., he-he-he-he-hit me.)
    • sound repetitions (i.e., p-p-p-p-pail),
    • syllable repetitions (i.e., ba-ba-ba babaseball)
    • audible prolongations (i.e., sssssss-snow)
    • inaudible prolongations, (i.e., g ------ irl)
  • Clustered disfluencies are a combination of part-word repetition and prolongation (i.e., m-m-m-mmmmmommy).
  • Common secondary symptoms (Behaviors may have been adopted by the speaker in an effort to minimize stuttering) include:
    • blinking of the eyes
    • facial grimacing
    • facial tension
    • exaggerated movements of the head, shoulders, and arms.

The Onset and Development of Stuttering

• Stuttering occurs between the ages of 2 and 5e and that the risk of developing stuttering is mostly over by the time the child is 3.5 years old.
• The onset of stuttering is gradual for the majority of children.
• Stuttering severity increasing as the child grows older.
• Bloodstein's Phases of Developmental Stuttering
  • Phase One - preschool years (the ages of 2 and 6)
    • stuttering tends to be episodic; periods of stuttering are followed by penods of relative fluency.
    • sound and syllable repetitions are the dominant feature, but there is also a tendency to repeat whole words.
    • most are unaware of the interruptions in their speech
  • Phase Two - children of elementary school age
    • stuttering is essentially chronic, or habitual, with few intervals of fluent speech.
    • child has developed a self-concept as a person who stutterers
    • occurs primarily on content words.
  • Phase Three - age from about 8 years to young adulthood.
    • stuttering is in response to specific situations fears,
    • certain words are regarded as more difficult than others
    • use of word substitutions and circumlocutions to avoid feared words
    • person will not avoid specific speaking situations
  • Phase Four - most advanced form.
    • primary characteristic is anticipation of stuttering.
    • certain sounds, words and speaking situations are feared and avoided
    • word substitutions and circumlocutions are frequent
    • secondary symptoms may be present at its onset

Theories and Conceptual Organizations of Stuttering Theory

• Organic theories propose an actual physical cause for stuttering.
  • Most well known is the theory of cerebral dominance or the "handedness theory" proposed by Orton and Travis (1930s).
  • Theory assumed that the muscles of oral mecahnism on the right and left side of the body received neural impulses from both the right and left cerebral hemispheres.
  • Assumed that one of the cerebral hemispheres was dominant over the other for issuing the neural impulses that controlled the temporal sequencing of speech. If one hemisphere was not dominant, a discoordination between the right and left halves of the speech musculature would exist that produced stuttering.
• Modified vocalization hypothesis
  • Asserted that stuttering was reduced greatly in conditions where voicing was absent (whispering) or modified in some way (singing, or speaking with delayed auditory feedback)
• Behavioral Theory
  • Behavioral theories assert that stuttering is a learned response to conditions external to the individual.
  • A prominent behavioral theory, the "diagnosogenic theory" was developed by Wendell Johnson (1940's and 1950's)
  • The differences between these two groups of children lay in the parental reactions to these hesitations.
• Psychological Theory
  • Psychological theory contends that stuttering is a neurotic symptom (internal conflicts) treated most appropriately by psychotherapy. Research indicates that psychotherapy is not an effective method for the treatment of stuttering.
• Current Conceptual Models of Stuttering
  • Covert repair hypothesis asserts that stuttering is a reaction to some flaw in the phonetic plan of speech.
    • Speakers can detect errors in the speech plan.
    • Persons who stutter have poorly developed phonological encoding skills.
    • Stuttering is a "normal" repair reaction to an abnormal phonetic plan.
  • The Demands and Capacities Model (DCM) asserts that stuttering develops when the environmental demands placed on a child to produce fluent speech exceed the child's physical and learned capacities.
    • Children who stutter presumably lack one or more of these capacities ( a balance of motor skills, language production skills, emotional maturity, and cognitive development) for fluent speech.

Indirect and Direct Stuttering Therapy

• Indirect Therapy
  • Indirect approaches are considered viable for children who are just beginning to stutter and whose stuttering is fairly mild.
  • Indirect therapy is designed to reduce communicative pressure
  • An important aspect of indirect therapy is information sharing and counseling where the parent is encouraged to reduce communicative pressure on the child and provide a slow, relaxed speech model for the child.
  • Play-ofiented activities that encourage slow and relaxed speech are the central component of such therapy.
  • There is no explicit discussion about the child's fluent or stuttering speaking behaviors.
  • The goal of indirect therapy is to facilitate fluency via environmental manipulation.
• DirectTherapy
  • Direct therapy involves explicit and direct attempts to modify the child's speech and speech related behaviors.
  • In direct therapy, concepts like "hard" and "easy" speech are introduced. Hard speech is rapid and relatively tense (like a tense sound prolongation of /s/ in sssssssss s- snake) whereas easy speech is slow and relaxed.
• Parental Counseling
  • Parental counseling is almost always indicated.
  • The parents require information about normal speech and language development.
  • The SLP needs to suggest ways that will help their child to speak in an easy effortless manner.
  • Parents and other family members should provide relaxed and slow speech models for the child.
  • Slow and relaxed communicative situations facilitate fluency by reducing pressure on the child to compete for time on the floor. Finally, parents should not pressure the child to talk or perform verbally.

Therapeutic Techniques Used With Older Children and Adults Who Stutter

• Fluency shaping techniques involve changing the overall speech timing patterns of the individual.
  • This is accomplished by lengthening the duration of sounds and words and greatly slowing down the overall rate of speech.

Modifying the Timing of Speech Movements

• Reducing the rate of speech, known as "prolonged speech" is one of the most frequently used techniques to reduce stuttering.
• Prolonged speech may be induced using delayed auditory feedback, or DAF.
• Speech rates ranging from 120 to 200 syllables per minute are typical targets for the termination of therapy.
• Pausing/phrasing is a therapeutic technique designed to lengthen naturally occurring pauses and to add pauses between other words or phrases.

Charles Van Riper developed three techniques that are introduced therapeutically in sequential order.

• Cancellation phase of therapy.
  • Individual is required to complete the word that was stuttered and pause deliberately following the production of the stuttered word.
  • Silent rehearsal of stuttered word is practiced during this phase and word is repeated.
• Pull-out phase of therapy.
  • Individual modifies the stuttered word during the actual occurrence of the stuttering.
  • Modification involves slowing down the sequential movements of the syllable or word when a stuttering occurs.
• Preparatory sets.
  • Slow-motion speech strategies that had been learned during the first two phases of therapy are used in anticipation of stuttering (not as a response to an occurrence of stuttering).
  • When an individual anticipates stuttering, he will start preparing to use the newly learned fluency producing strategies before the word is attempted.

The Effectiveness of Stuttering Treatment

• Treatment for stuttering might be considered effective if it resulted in the individual's being able to speak with disfluencies within normal limits.
• Efficacy of Therapy With Preschool-age Children
  • Findings of 9 investigations regarding the effectiveness of treatment involving 160 school-age children indicated a 61% average decrease in stuttering frequency..
• Efficacy of Therapy With Teenagers and Adults
  • Teenagers can be difficult to manage clinically and little information is available regarding specific therapy programs for this age group.
  • Many reports of treatment outcomes regarding the adult suggest a 60% to 80% improvement rate regardless of the therapeutic technique that was used.
  • Stuttering treatment across all age groups results in an average improvement for about 70% of all cases with preschool age children improving more quickly and easily than persons who have a longer history with stuttering.