Awarness articles

• Speech is a remarkable and complicated process involving a variety of linguistic, cognitive and sensorimotor processes.
• Fluent speech is the consistent ability to move the speech organs in an effortless, smooth and relatively rapid manner resulting in a continuous, uninterrupted forward flow of speech.
• Developmental dysfluency can be considered a normal part of childhood development.
• Some children experience some fluency problems.
• Symptoms of developmental dysfluency include repetitions of sounds or pauses between words, for example, the child might say; "Daddy, I was, I was, um, um, I was...". These symptoms have generally been noted within youngsters during preschool age. They may persist for weeks or months but eventually disappear due to maturation of the child's nervous system.
• Instances like the aforementioned example, indicate, that the child is learning to use language. On the other hand, children with stuttering disorder, will likely repeat sounds. They may also prolong sounds for two or more seconds. In comparison, stuttering can be seen as a process where a word appears to become "stuck," and the person may grimace, jerk the head or neck as he struggles to overcome the stutter.
• Children with normal dysfluency tend to have stuttering difficulties that come and go. Generally this is during preschool years and the problem normally ceases altogether by the time a child starts school.
• The etiology and mechanisms of developmental speech dysfluency are complicated and a matter of some debate. In general, it signals a lack of coordination between linguistic intention and motor articulation as children learn to talk and think at the same time.
• Most children outgrow the period of dysfluency, but those who do not will require speech therapy, so it is important that a distinction be made between childhood dysfluency and stuttering. Stuttering is a disturbance in the normal fluency and time patterning of speech that is inappropriate for the person's age. We all experience periods of dysfluency — normal speech includes 2%–4% interruptions in flow or fluency. Generally speaking, revisions, interjections and word and phrase repetitions are very common in children's speech; sound and syllable repetition, sound prolongation and broken words are more atypical.
• Speech patterns and behaviors that might signal that a child is at risk of stuttering include:
  • Within-word or part-word repetitions
  • Prolonged sounds
  • Avoiding speaking situations or saying “I can't say it”
  • Looking upset
  • Speaking with tension in the face or neck muscles or voice
  • Speaking with unexpected rises in pitch or loudness
  • Boys are 4 times more likely than girls to develop a stutter
  • Children with a family history of stuttering are more likely to stutter than children without
• Normal Dysfluencies
  • 2 years of age, typical dysfluencies 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 dysfluencies persist throughout the course of one's life, but they do not tend to affect the continuous forward flow of speech adversely.
• In early childhood, stuttering begins as an initial increase in the amount of dysfluencies.
• Stuttered Dysfluencies
  • Stuttering or stuttered speech involves:
    • part-word repetitions.
    • sound prolongations.
    • monosyllabic whole word repetitions.
    • within-word pauses.
    • audible or inaudible repetitions or prolongations of word/syllable fragments.
    • periods of silence between words/syllables.
  • Dysfluencies that occur within a word unit that are likely to be regarded as stuttering includes:
    • 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 dysfluencies 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 TWO MAIN FORMS OF DYSFLUENCY ARE:

STUTTERING:

Stuttering is an interruption of the speech flow. Stuttering can be defined as:

• All types of dysfleucnies that exceed a measure such as 5% of spoken words
• Production of particular word repetitions and speech-sound prolongations
• Moments or events judged to be stuttering
• Anticipatory, apprehensive, hypertonic (increased tension), and speech avoidance reactions

CLUTTERING:

Cluttering includes rapid but disordered articulation possible combined with a high rate of dysfluencies and disorganized thought and language. When dysfluencies exceed 5% of words spoken, listeners tend to judge the speech as dysfluent or stuttered. Examples of stuttering include:

• Involuntary repetitions of sounds, syllables, or phrases e.g. (b-b-b- ball), or (ba-ba-ba- ball)
• Sound prolongations / mistiming: this refers to prolongation of sounds and / or syllables e.g. (mmmmmmmm-mum)
• Blocks / silent pauses (silent intervals between or within words especially when they last more than 2 seconds)
• Tense pauses
• Hesitations
• Broken words e.g. (b----oy)
• Interjections (sound / word fillers): these are extra sounds, syllables or words that add no meaning to the message but the person who stutters can sometimes use them to overcome stuttering moments as it gives him time to formulate his thoughts.
• Incomplete phrases
• Revisions (the habit of stopping in midstream and starting over in a new direction)
• Secondary characteristics–such as rising intonation, breathing problems, facial grimacing, head movements, avoidance of eye contact, or hand movements, negative emotions and avoidance behaviors tend to develop in due course and to varying extents across individuals.

N.B.

Stuttering occurs at such predictable loci such as:

• Initial sounds and words
• Consonants
• Longer and unfamiliar words
• Content words (in older children and adults)
• Function words (in younger children)

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 periods 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
  • speech avoidance and social isolation

Though there are many theories as to what may actually cause one to stutter, there is currently no conclusive evidence indicating any definitive single cause. Genetics may play a significant role. Current evidence also indicates a neurological component related to a lack of cerebral dominance in individuals who stutter.

THEORIES AND CONCEPTUAL ORGANIZATIONS OF STUTTERING THEORY:

• Organic theories propose an actual physical cause for stuttering.
  • The 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 mechanism 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.

ASSESSMENT OF STUTTERING INCLUDES:

• A detailed case history
• Measurements of types and frequencies of dysfluencies in conversational speech and oral reading
• Evaluation of the variability of dysfluencies; assessment of:
  • Negative emotions
  • Avoidance reactions
  • Associated motor behaviors
• Measurement of speech and articulatory rates
• Application of a chosen diagnostic criteria

Treatment of stuttering varies across the developmental stages. In treating younger children, therapy is indirect and focuses on practice and use of smooth, slow and easy speech. In treating older children, the presence of stuttering is addressed more directly and specific techniques are taught. Therapy also focuses on feelings and attitudes towards speaking and stuttering.

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-oriented 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.
• Direct Therapy
  • 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. Finally, parents should not pressure the child to talk or perform verbally.

EXAMPLES OF SOME OF THE THERAPEUTIC TECHNIQUES THAT CAN BE USED WITH OLDER CHILDREN AND ADULTS:

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.
• 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 (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.