1. Chapter 12: Fluency Disorders Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

2. Focus Questions What is a fluency disorder? How are fluency disorders classified? What are the defining characteristics of fluency disorders? How are fluency disorders identified? How are fluency disorders treated? 12.1 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

3. Introduction – Fluency Disorders Ability to produce speech effortlessly and automatically is compromised Better known as stuttering Relatively small number of persons affected compared to other communication disorders – 1 to 2% of population at a given time 12.2 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

4. The Familiarity of Stuttering Despite the low incidence, the general population seems to be most familiar with fluency disorders – WHY? –Perhaps longest documented history of any communication disorder –Affected some famous faces, including contemporary celebrities –Often used in the media, either comically or as a dramatic, metaphoric technique 12.3 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

5. What you may not know… Most young children go through a period of disfluency (up to 5% of their speech) Majority of cases in children are resolved, either spontaneously or through treatment Many of the public perceptions of people with fluency disorders are not accurate, such as being timid or fearful 12.4 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

6. Case Study #1: Ralston 4-year old boy in private day care center in West Virginia –family (consisting of mother, father, and four siblings) lives in two-bedroom subsidized apartment Social and communicative child, but recently day care teacher has noticed stuttering and more frequent temper tantrums Mother says not to worry, that older siblings also went through this stage, but teacher is worried that the stuttering might interfere with Ralston’s interactions with the other children and that it might be related to the tantrums 12.5 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

7. Case Study #1 Questions What warning signs should Ms. Henry look for when documenting Ralston’s stuttering behaviors? What are some strategies Ms. Henry might use in the day care center to promote Ralston’s ability to effectively communicate? What are some events or challenges in Ralston’s life that might be related to the emergence of disfluencies? 12.6 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

8. Case Study #2: Kaimon 7-year old boy just starting second grade –treated for fluency disorder in K – 1 st grades, but dismissed from treatment Mr. Damon, teacher, reports that Kaimon is still stuttering and using avoidance tactics Kaimon doesn’t want to go to therapy again, and his teacher agreed to try different strategies in the classroom for next three months 12.7 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

9. Case Study #2 Questions What are some strategies that Mr. Damon might use to promote peer acceptance of children with communication disabilities in his classroom? What are some strategies that Mr. Damon might use in the next few months to increase Kaimon’s fluency and decrease his disfluency within the classroom? Do you agree or disagree with Kaimon’s parents for keeping him out of therapy for the next few months? Why or why not? 12.8 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

10. Case Study #3: Mr. Cho 39-year old suffered a stroke during heart surgery –paralyzed on right side and exhibits communication impairments, including severe fluency problem Shows pauses, interjections, repetitions, and prolongations, but no fear or embarrassment Insurance only covers 12 sessions of outpatient therapy, but he’s using those for physical therapy Decided to pay out-of-pocket $1,200 for a 3-month vitamin treatment that claims 100% cure for acquired stuttering that his daughter found advertised in the newspaper 12.9 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

11. Case Study #3 Questions Do you agree with Mr. Cho’s decision to forfeit the outpatient speech therapy in lieu of the physical therapy and to pursue the vitamin treatment? How can a consumer differentiate between those treatments that are effective and those that are questionable? What other explanations are possible to explain Mr. Cho’s improved fluency following two months of a special vitamin regimen? 12.10 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

12. I. What is a Fluency Disorder? What is fluency? –Speech moves at an appropriate rate –Easy rhythm –Smoothness –Effortless –Automatic Disfluency occurs when there is a disruption in any of these elements 12.11 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

13. Fluency Disorders Unusually high rate of stoppages that disrupt the flow of communication and re inappropriate for a person’s age, culture, and linguistic background Three essential characteristics: –Disturbance in the normal fluency and timing patterns of speech –Disturbance in social communication, academic performance, or occupational achievement –If another disability is present, the fluency disturbance is in excess of what is expected of that disability 12.12 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

14. Core and Secondary Features Core features: primary characteristics of a fluency disorder –Repetitions –Prolongations –Blocks Secondary features: emerge in response to the core behaviors –Avoid and escape moments of disfluency, such as eye blinks, head jerks, pauses, fillers –Negative feelings and attitudes, such as worrying about speaking, viewing speaking as difficult 12.13 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

15. Terminology Stuttering: describes fluency disorder Stutterer: describes a person affected by a fluency disorder Person first language gives the individual primacy over the disorder (e.g., “child who stutters”) 12.14 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

16. Prevalence and Incidence Incidence: 1 in 100 persons Prevalence: 5 in 100 persons Affect children between the ages of two and 10 years at the highest rates Males are affected at a higher rate than females (approximately 3:1) 12.15 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

17. Recovery from Stuttering Difference between prevalence and incidence rates indicate that the majority of persons (perhaps 80%) who exhibit fluency disorders do recover Raises question concerning need for treatment (i.e., to treat or to wait and see) Three reasons why treatment is necessary: –Children who recover from stuttering often do experience stuttering for a relatively long time –No way to know whether children will eventually recover or not –Relatively high rate of co-occurring speech and language problems that exist beyond fluency disorder 12.16 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

18. II. How are Fluency Disorders Classified? A. Etiology-Focused Classification Developmental Disorder of Fluency: –Emerges in early childhood (2-5 years) and its cause is unknown –Characterized by stuttering-like dysfluencies (SLDs): part- and single-syllable word repetitions, prolongations, and blocks Acquired Disorder of Fluency: –Dramatic onset anytime in lifespan, resulting from illness, trauma, accident, or psychological trauma 12.17 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

19. B. Symptom-Focused Classification Several systems exist to describe fluency disorders in terms of how far they have advanced Peters and Guitar’s 5-Level System: –Normal disfluency: 18 mos. – 6 yrs. of age –Borderline stuttering: (18 mos. – 6 yrs.) produce more and different types of disfluencies than normal –Beginning stuttering: (2 – 8 yrs.) true fluency disorder –Intermediate stuttering: 6 – 13 years –Advanced stuttering: over 14 years 12.18 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

20. Cluttering Cluttering: –Breakdowns at the word or phrase level –Poor cohesion and coherence in expressing thoughts and organizing sentences –Fast and spurty speaking rate –Reduced intelligibility –NOT inhibited or anxious about speaking 12.19 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

21. III. Defining Characteristics of Fluency Disorders Core Features –Within-word and between-word disfluencies Secondary Features –Escape behaviors –Avoidance behaviors –Feelings and Attitudes Causes and Risk Factors –Predisposing factors –Precipitating factors 12.20 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

22. Core Features 1.Part-word repetition: sound or syllable is repeated 2 to 4 times 2.Single-syllable word repetition: two or more times 3.Sound prolongation: duration of speech sound is lengthened 4.Block: articulators and airflow completely stop during the production of a sound Within-word disfluencies (stuttering) vs. between-word disfluencies (normal) 12.21 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

23. Secondary Features Escape behaviors: response to moments of stuttering –Head nods, eye blinking, leg slapping Avoidance behaviors: avoid moments of stuttering –Word and sound avoidance (substitution, circumlocution, postponement) –Situation avoidance Feelings and attitudes: negative feelings towards communication –Fear, embarrassment, shame 12.22 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

24. Causes and Risk Factors For the majority of children, stuttering begins for no apparent reason Hard to identify, because results from complex interaction of two types of factors: –Predisposing: individual’s constitutional factors that make him susceptible to a fluency disorder (70% of likelihood) –Precipitating: developmental and environmental factors that can worsen stuttering (30%) 12.23 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

25. Predisposing Factors Family history: tendency to run in families, and genetic link seen in twin studies Gender: boys are more likely to develop a fluency disorder and slower to recover Processing ability: underlying problem with linguistic processing (demand and capacity model) Motor-speech coordination: difficulty in coordinating and timing the motor activities required for fluent speech 12.24 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

26. Precipitating Factors Age: average age of emergence is 3 years for boys and 2.5 years for girls Development stressors: –Stressful adult speech models: children exposed to adult speech not appropriate for their own speech, language, and cognitive abilities –Stressful speaking situations for children: competing or hurrying to speak, having too many things to say –Stressful life events: moving, divorce of parents, loss of family member, illness, or accident Self awareness: atypically high awareness of own disfluencies 12.25 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

27. IV. How are Fluency Disorders Identified? Determine if the quality and/or quantity of disfluencies significantly differ from normal Quantity: two common metrics –Average # of disfluencies per 100 words –Average # of disfluencies per 100 syllables Quality: –Normal: interjection and revisions predominate –Disordered: repetitions, prolongations, and blocks predominate 12.26 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

28. The Assessment Process Referral Assessment Protocol Diagnosis Severity Prognosis Treatment Recommendations 12.27 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

29. Referral Important for other professionals to recognize warning signs and make referrals to SLPs Warning signs for developmental fluency disorders: –Repetition of words or parts of words that involve 3 or more repetitions, prolongation of a sound, feelings of frustration or embarrassment towards communication Warning signs for acquired fluency disorders: –“stuttering-like” or “cluttering-like” disfluencies, inability to effectively communicate 12.28 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

30. Assessment Protocol Four main questions: 1. Is the child stuttering or at-risk for stuttering? 2. Does the child exhibit other communicative risk factors or disabilities? 3. Is therapy for stuttering warranted? 4. What therapy approach is most beneficial? 12.29 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

31. Assessment Protocol Variety of tools: –Case history and interview –Speech observation –Questionnaire and survey –Direct testing 12.30 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

32. Diagnosis More likely to be diagnosed if the following are observed during assessment: –At least 10 total disfluencies per 100 words –At least 3 total “stuttering-like” disfluencies per 100 words –Physical escape behaviors –Verbal avoidance behaviors Also need to determine the severity, prognosis, and treatment recommendations 12.31 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

33. Severity: –Stuttering Severity Index (SSI): based on frequency of disfluencies, duration of blocks, and physical concomitants very mild, mild, moderate, severe, very severe Prognosis: –Subjective decision of likelihood that the symptoms will resolve with time and/or treatment based on several factors (e.g., age of onset, presence of other risk factors) Treatment Recommendations: –Specific course of action based on evidence- based practice 12.32 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

34. V. How are Fluency Disorders Treated? A. Borderline Stuttering: Early intervention vs. “wait and see” approach Indirect treatments: –Environmental modification models –Operant training models 12.33 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

35. B.Beginning Stuttering Treatment goal: eliminate core disfluencies (secondary are not apparent yet) Current Approaches: –Stuttering modification therapy –Fluency shaping therapy 12.34 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

36. C. Intermediate and Advanced Stuttering Secondary features now characterize these levels Treatment for adolescents: –Already a challenging period of life –Stuttering modification: teaching about stuttering and how to work through it –Fluency shaping: smooth speech treatment Treatment for adults: –Emphasizes knowledge about stuttering, reduction of negative feelings, and fluency building –Pharmaceutical intervention is being explored 12.35 Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.