stuttering: an overview

1. Stuttering: an overview

3. Distinguishing disfluency from dysfluency Normal disfluency can be distinguished from dysfluency on the bases of: Frequency Quality Accompanying features (overt and covert)

4. Normal disfluencies Normal disfluencies include: Repetitions (of sounds, syllables, words and phrases) Prolongations (of syllabic elements, usually for emphasis, or to gain planning time) Unfilled pauses or hesitations Filled pauses Revisions

5. Fluency and dysfluency A. There is a noticable lack of fluency in normal speech production. Goldman-Eisler (1968) estimated that filled and unfilled pause time averaged 40-50% of overall speaking time in picture description tasks. B. There is some evidence that these disfluencies are necessary to allow on-line speech production. 1. Beattie & Bradbury (1979). When subjects paused for more than 600 msec. in story-telling, a light went on. Subjects were told that it indicated poor story-telling. Pauses decreased by 35%, but repetitions of words and syllables went up 104%, while the narrative quality declined as well. 2. Lindsley (1976). It took his subjects reliably longer to initiate a noun-verb sequence than a simple noun when describing pictures. Subjects need to plan ahead a certain distance, and need planning time to accomplish this.

6. Fluency and disfluency (continued) 3. Beattie (1983) has noted gaze aversion during disfluencies, suggesting that the speaker is preoccupied with planning and cannot be distracted by eye contact. 4. Eye gaze patterns in normal speech: In most American dialects, speakers may look away, while listeners should look at the speaker (Mayo, 1967). What are the ramifications for variations in this pattern?

7. Fluency and disfluency (continued) C. Patterns of pauses and disfluencies (loci studies) 1. They are quite reliably located a major constituent boundaries, with the exception of those occurring before abstract or infrequent lexical items. Some have suggested that filled pauses are usually used for syntactic planning, while unfilled pauses usually precede lexical search. (Maclay & Osgood) 2. Beattie (1983) suggests that the macro-unit for discourse processing may be as large as eight clauses in length, because disfluencies tend to rise and fall in about eight-clause cycles.

8. Fluency and disfluency (continued) 3. Factors which tend to aggravate normal fluency: a. stress b. high cognitive loading c. increased linguistic/syntactic demand - especially true in children d. fatigue e. speed

9. Cardinal features of stuttering Part-word repetitions In normally fluent speech, incidence of <2%, <10% of all disfluencies In stuttering >2% incidence, and ~50-75% of disfluencies In normally fluent speech, <2 repetitions; in stuttered speech >2 repetitions Repetitions accompanied by tenseness, rapidity, disrhythmia, schwa vowel, awareness

10. Cardinal features (continued) Prolongations Longer in stuttered speech On elements not typically prolonged in fluent speech Not used for planning or emphasis Blocking (virtually unique to stuttering)

12. Stuttering DEVELOPS and changes over time Stuttering at onset may be very different from what it becomes as the child grows and develops coping strategies to deal with stuttering and the reactions s/he gets when talking

13. Exercise: comparing normal and stuttered disfluencies Listen to the following samples and follow along on the transcripts: What features are common to both speakers? What features distinguish the two speakers?

14. �Mike� Interviewer: What do you think the President�s top priority should be this year? M: Uh, the economy. I think if uh the -- I think if you solve a lot of the uh economic problems you�ll solve a lot of other problems, you know uh�you know, when economics or when the � when people are out of work, don�t have money, crime goes up, drug use goes up. Uh I think you have you know a psychological type of disorders go up..You know, people become a little bit �anxious, and I think..if you solve that � if you can help rel� uh resolve that problem� I mean you�ll help solve a lot of other problems. You know, we we won�t be as tight with other people. I � n- not tight, tight in the sense of money, you know, you�you know, people are�right now, you know, �why give money to this country � why do this you know for these people � why do this for that?� And you know, I- it�s � the reason is because they don�t have a job or they�re afraid they�ll lose their job and there won�t be money for them if they have to collect or � you know, that that type of uh anxiety.

15. �Tom� That's possible, yeah. But I've gone through all kinds of programs and I've read up on what I think that how stuttering can sometimes be cured through psychological counseling. So when I read that it's like , 'Oh yeah that's the new hope�� I'm just that way because of my past failures. I know, but it's just that I tend to look forward rather than dwell in the present which isn't always good. Well, let's see� I would say being called on in class or being where a teacher would say, 'Let's go in a circle for group discussion'� And he starts on the opposite side of the room� and I just happen to be the last one. That's the worst case.

16. Accessory behaviors (�secondaries�) Usually appear later in development Appear learned and reactive Differ from PWS to PWS May include: Physical concomitants Tension and tremor Anticipatory behaviors, postponements Timing devices Escape behaviors Breathing irregularities Circumlocutions

17. How do secondary behaviors develop? Classical conditioning Operant conditioning

18. Classical conditioning

19. Chaining of stimuli in stuttering

20. Instrumental conditioning

21. Combining classical and instrumental conditioning in stuttering

23. Covert features Speaking fears (including fears of situations, addressees, targets) Fear of stuttering Avoidance Shame, guilt Belief systems

24. What is stuttering? The ABCs

25. The As and Cs of stuttering in pictures

28. What does stuttering sound like, look like, feel like? See some examples of what stuttering Sounds like Looks like Feels like At the StutteringHomePage: http://www.mankato.msus.edu/dept/comdis/kuster/audio.html

29. Impairment, disability and handicap in stuttering (ICIDH; Yaruss & Quesal) Impairment: �any loss or abnormality of psychological, physiological, or anatomical structure or function.� In stuttering: interruptions in the flow of speech Disability: �any restriction or lack of ability to perform an activity in the [normal] manner� In stuttering: limitations on the individual�s ability to communicate or engage in social or vocational activities Handicap: �a disadvantage for an individual, resulting from and I or D that limits�the fulfillment of a role that is normal..for that individual.� In stuttering: disadvantages experienced by the PWS that limits his/her ability to fulfill social, vocational or economic roles.

30. Stuttering: Impairment, Disability and Handicap (Yaruss)

31. Stuttering doesn�t have to handicap: some famous examples

32. Exercise: Observing stuttering Making behavioral observations Actions or speech that are directly observed Observations should not reveal judgments, interpretations or opinions Examples: The client repeated the /t/ sound three times on the word time. The client stated that her father stutters but that the subject of stuttering was not discussed at home. The client grimaced and said, �This is boring.�

33. Making inferences The observer�s interpretation of the observation. These may vary from observer to observer and will be influenced by the observer�s beliefs, past experiences, values, culture, training, etc. Examples: The client demonstrated a core stuttering behavior The client�s father experiences guilt and shame regarding his stuttering The clinician�s materials and pacing were not appropriate to the client�s age.

34. Observations and inferences What core and secondary behaviors did you observe? What feelings and attitudes were expressed? How? What other aspects of the nature of stuttering were revealed in the video clips?

35. The typical typology of stuttering symptoms Where stutters are typically found: On utterance-initial syllables Initial consonants Words earlier in the utterance Longer, less frequent words of the language (adults) Shorter, function words (children) The consistency effect The adaptation effect

36. Conditions which reduce the frequency of stuttering Delayed auditory feedback (DAF) Frequency altered feedback Slowed speech Shadowing Singing Rhythmic speech Choral reading Lipped speech Whispering Why do you think these reduce stuttering? What are some common features of these adjustments to normal speech style? Question: can these be used as therapy techniques?

37. Conditions which tend to INCREASE stuttering Fear of stuttering/speaking Expectancy Time pressure Status gap/number of addressees Propositionality, linguistic and cognitive load Learned associations Other listener reaction variables What do these have in common with conditions that aggravate normal disfluency?

38. Specific examples of conditions that tend to increase stuttering severity Speaking on the telephone Saying one�s own name Telling jokes Repeating a misunderstood message Waiting to speak Speaking in front of authority figures, audiences Hiding/avoiding stuttering (trying to be fluent)

39. Stuttering: Incidence and prevalence Incidence is ~4%, prevalence is ~1% Implications for recovery Implications for treatment Most common type is developmental and ideopathic, beginning between 2-4 years of age Later or adult onset is rare, usually accompanied by neurological insult or psychological trauma; however, some late childhood onsets are unexplained. Newer data (Yairi, et al., 1996; Kloth, et al., 1995) suggest median onset age of 30-38 mos.

41. Gender and fluency Boys are 3-4 times more likely to stutter than girls; this imbalance increases with age Gender differences are less at onset, but girls appear to recover more frequently (Yairi, et al., 1996)

42. Genetics and stuttering First degree relatives of PWS more than 3x more likely to stutter than general population ~35% of sons of female PWS will stutter 17% of daughters of female PWS will stutter 22% of sons of male PWS will stutter 9% of daughters of male PWS will stutter Patterns of chronicity and recovery also appear to be inherited (Yairi, et al.), although severity and typology are not.

44. Twin studies There is 77% concordance between monozygotic twins for stuttering Lack of full concordance does suggest possible environmental contributions What is environmental? Dizygotic twins have a 32% concordance rate, while non-twin siblings have an 18% concordance rate.

45. Recovery from stuttering 80% of stuttering spontaneously resolves before age 16; however, The window for recovery appears best within 2 years of symptom onset (Yairi, et al., 1996) Recovery at older ages diminishes in frequency, to less than 20% by age 10 (Andrews, et al., 1983); Ramig (1993) suggests this rate is even lower after age 8.

47. Stuttering terminology Stuttering has an extensive lexicon to describe symptoms, features, theoretical models, treatment approaches, etc. See an online listing, with definitions

48. Keeping up with the stuttering literature To search the latest developments In stuttering, or research your project/paper, go to: http://www.ncbi.nlm.nih.gov/PubMed/ (PubMed) Remember that ASHA journals are now on-line! (If you are not a NSSHLA member, join now!) Remember to distinguish between information found on the web, and peer-reviewed data. Do statistics confuse you? Here is a readable tutorial on how to read the stats in research articles Good �lay� sites to introduce yourself and your clients to information about stuttering: http://www.stutteringhomepage.com NSA and SFA websites http://www.nspstutter.org/ http://www.stuttersfa.org