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Fluency

WHAT IS IT?


It is a speech pattern that contains an abnormal amount of disruptions that stop the forward flow of speech due to their frequency or duration.

A disruption in speech is called a disfluency.

We all have disfluencies in our speech ("uh", "um", "er" pausing or re-wording), but it is only considered to be a stutter when you are disfluent more than 10% of the time.

To understand this disorder you need to understand what fluency is.

Fluency is the effortless flow of speech.

This disorder affects all 4 parts.

  1. Continuity - the smoothness of speech, how much speech is affected by disfluency.
  • Continuity is decreased by how often and where pauses happen in speech and by how many extra sounds are added such as "um", "well", "uh", repeating or re-wording.

       2. Rate - how fast or slow speech is, it is measured by words/syllables spoken per minute and relates to information flow as well as sound flow.

Example:The rate of information and sound flow is too slow for people who stutter and too fast for people who clutter. That's why it can be harder to listen to them.

  1. Rhythm - the rhythmic pattern of speech which depends on intonation, stress pattern, timing, and duration.

Example: People who with this disorder have disruptions that are louder, longer, and slightly higher pitched. This is what makes disfluencies more noticeable.

  1. Effort - how much mental or physical work it takes to talk. Normal speech is not effortful.
  • People with this disorder use more effort to talk because they're trying to sound "normal." It takes mental effort to think ahead of time about what words you'll get stuck on. It takes physical effort to stop or "escape" getting stuck on a word.

Boys are 3 times more likely than girls to have the disorder. 80% of children ages 2-5 who develop this disorder will recover on their own (spontaeous recovery).

There are certain conditions that make it better or worse. For example singing and choral speech/reading (reading or speaking out loud with others) increase fluency.

Activities like talking on the phone, saying your name, giving a speech, or with increased time pressure decrease fluency (makes it worse).

While reading, adults with this disorder can predict which words they will get stuck on. Also, they will always get stuck on the same words if they read it again. However, if they practice reading or reciting, disfluency decreases.
 

WHAT IS A STUTTER DISORDER?


It is a multi-dimensional disorder that is made up of 3 parts.

  1. Core Behaviors - accidental disfluencies that a person who stutters can't control. There are 3 types:
  2. Repetitions - repeating a sound, syllable, or one syllable word more than once or twice.                                                                        Example: "The b-b-b-baby is crying" (sound) "I think the bu-bu-bu-bunny is hungry" (syllable)                                                              "Can, can, can I come with you?" (word)
  3. Prolongations - holding out a speech sound but the mouth/lips/tongue has stopped moving                                                         Example: "Caaaaaaaaaaan I come too?"
  4. Blocks - when sound or air is stopped in the lungs, throat, or mouth/lips/tongue                                                                                Example: "Can..............I come to?

Children usually begin with the mildest type of disfluency - repetitions. The repetitions are often bouncy and easy and children are typically unaware of them in the beginning.

As time goes on, it advances to prolonongations and blocks and the repetitions become faster and tension increases. That said, 33% of children with this disorder start with prolongations or blocks.

Secondary behaviors begin to develop as the disorder and awareness of it increase.

  1. Secondary behaviors - learned reactions or responses to the disorder. These are classified into many types.
  2. Escape Behaviors - when a speaker tries to get out of being stuck on a word, with a physical movement. These can come in many forms such as eye blinking, foot stomping, and head turning etc.
  3. Avoidance Behaviors - when the speaker thinks he is going to get stuck and does something to prevent it from happening.
  4. Negative Feelings and Attitudes                                                                                                                                                                               a. Feelings - a person who stutters can feel fear, shame, guilt, hostility, frustration, and embarrassment.                                       b. Attitudes - the negative feelings a person feels can change their whole attitude about talking, others, and themselves. These can be hard to discover and change.

The basic types of fluency disorders are:

     developmental (page coming soon)

      cluttering (page coming soon)

       neurogenic disfluency - sudden, caused by head trauma

       psychogenic disfluency - due to an emotional crisis that doesn't last long

 

PRE-DISPOSING FACTORS

(This is not what causes stuttering, they are just conditions that can make a person at-risk for it)


Heredity

Stuttering runs in families

Girls are less likely to stutter than boys

Genetic factors are stronger in women who don?t recover (because most do).

Thus, their relatives are more likely to stutter 80%-90% of siblings stutter if their identical twin stutters

Problem with Cerebral Localization

  • People who stutter could have a delay in the development of the left side of their brain which could affect speech and language
  • This delay happens during fetal development
  • They may use the right side of their brain for speech and language instead of the left side like usual
  • Using the right brain for speech and language is not as efficient as using the left

Problem with Timing

  • People who stutter could have a deficit in temporal programming (or timing of their speech movements)
  • Their speech and language centers are not in the usual place so it takes longer for them to program their speech movements
  • Other brain functions can interfere with the timing of speech movements; for example, increased emotion, controlled by the right side of the brain, such as when a child is upset or excited, can make the child stutter because it got in the way of the timing


Problem with Language Production
(Covert Repair Hypothesis, Postma and Kolk)

  • People who stutter may have an impaired phonological encoding mechanism (basically they could have something wrong with the place in their brain where speech is planned and programmed)
  • Activating or saying sounds is a little delayed for people who stutter
  • People who stutter try to speak faster or start speaking too quickly
  • They don’t wait long enough for their slow-to-activate speech planner (delayed phonological encoding mechanism) to choose and plan the right sounds before talking

 

  • If phonological encoding error is detected, the speaker may attempt to covertly repair the error before it is articulated which results in disfluency (stutter)
  • If an error in the speech plan is detected, the brain unconsciously goes through different sounds/words until the correct sound/word is found, this causes the disfluency or stutter


Problem with Language Complexity

  • Motor control of speech is worse when the language or message is more complex
  • Children stutter more when they are saying bigger/harder words, using more difficult grammar, and when the sentence is longer (Bernstein Ratner & Sih, 1987, Yarruss, 1997)

No matter what pre-disposing factors look at it is important to know that there is a lot of evidence to show that people who stutter DO have a physical difference in their brain.

BUT remember...

...just like other areas of speech and language; the brain is altered by experience because of its ability to change (plasticity).

People who stutter have been able to see changes in their different brain activity, after going through successful stuttering therapy.

Bottom line, just because there is a physical brain difference, it does not mean it cannot be cured and it is not necessarily part of stuttering causes. This is definitely an awesome finding for people who stutter and for speech therapists who offer stuttering therapy.

Stuttering therapy is much more than teaching someone to "talk slower". SLPs use the following approaches when treating a person who stutters.

  1. Stuttering Modification Therapy -where SLPs teach you to stutter more fluentlywith less tension and struggle, learn to stutter in a more relaxed manner which will help you be more fluent.
  2. Fluency Shaping Therapy- where SLPs teach you to speak more fluently by using a slow rate of speech, decreasing length/complexity of the message, reinforcing fluency and carrying over fluency skills to other situations.

These 2 therapy approaches can also be combined and used at different stages of therapy depending on what will be best for the person who stutters.

SLPs also choose different goals or outcomes from therapy depending on the level of stuttering they are treating. The 3 main goals of treatment are:

  1. Spontaneous Fluency - to speak normally and without thinking about being smooth
  2. Controlled Fluency - to speak with slow rate and rhythm but still sound normal, takes more effort because you are using strategies
  3. Acceptable Stuttering -to openly stutter without fear or much embarrassment
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