Notes from Text (Guitar) and other resources

ASHA's definition:  A fluency disorder is an interruption in the flow of speaking characterized by atypical rate, rhythm, and repetitions in sounds, syllables, words, and phrases.  This may be accompanied by excessive tension, struggle behavior, and secondary mannerisms.
Scope of practice:  Screening, identifying, assessing and interpreting, diagnosing,
rehabilitating and preventing disorders of speech (e.g., articulation, fluency, voice, and
language (ASHA 1983, 1989).

In essence- fluency is a speaker’s effortless flow of speech

What is stuttering?

Four definitions are historically significant

Van Riper’s(1939) stuttering occurs when a forward flow of speech is interrupted abnormally by repetitions or prolongations of a sound, a syllable or an articulatory posture or by avoidance and struggle behavior

Wingate-(1964) Stuttering is an abnormally high frequency and /or duration of stoppages in the forward flow of speech.

These stoppages usually take the form of
(a) repetitions of sound, syllables, or one-syllable, words,
(b) prolongations of sounds
(c) "blocks" of airflow and/or voicing in speech.
(introduces a lack of control concept

Nicolosi and Colleagues-(1978) "timing disturbance" characterized by

1 audible or silent blocking
2 sounds and syllable repetitions,
3. sound prolongations
4. interjections
5. broken words
6. circumlocutions,
7. words produced with tension
accompanied by associated behaviors(secondary characteristics--may be at the level of therespirator, phonatory, or articulatory mech. (introduces idea of etiology)

Perkins and Asso.

Stuttering is a multifaceted disorder --inability to control the neuromotor timing of syllables caused by an undetected abnormal neurolinguistic (neuroanatomical basis of speech and its disorders) problem that cause discoordination between various systems (elements that are related to the continuation of the behavior. 

Perkins, Kent, and Curlee Theory
Stuttering results from a dyssynchrony between two components of language.  One component is a paralinguistic-- a right hemisphere social-emotional system that is responsible for vocal tone and prosodic functions.  The other component is linguistc--a left hemisphere segmental system that is responsible for the content of languae, its semantics, syntax and phonology. (a dyssynchrony of segmental and suprasegmental elements for speech in the development of speech motor programs) The two components must be integrated before language is produced.  If one lags behind, the resulting dyssynchrony produces disfluencies.  In addition, the person must experience time pressure, and must feel  a subjective feeling of loss of control. f the speaker experiences time pressure to speak and his disfluency is out of his control, the disfluency is stuttering.

Perkins (1990)

Stuttering is not what we count as dysfluencies, but "Stuttering is the involuntary disruption of a continuing attempt to produce a spoken utterance"

He states- "Stuttering is not what is perceived by the listeners as stuttering in the
acoustical signal, but rather what occurs in the production of stuttered speech" i.e.,
stuttering is the involuntary disruption of speech.  There is a feeling of being "out of control".

"What is frustrating and can become frightening, about stuttering is that when it happens,
speech is either about to be or becomes temporarily disrupted for reasons the stutterer is unable to prevent" (p. 376)
 
                                            Culatta-

                              Four factor definition of stuttering-

Factor One: Stuttering is a developmental disorder of childhood- most often identified between the ages of 2.5 to 4 years.

Factor two- The cause of stuttering is unknown

Factor three Clients view communication differently from normal speakers--They have learned to expect different consequences from their attempts at speech than normal speakers--must consider the client’s perception of the disorder

Factor four- Clients have abnormal overt or covert communication behaviors.- including
hesitations, broken words, repetitions, interjections, prolongations, dysrhythmic phonations, visible tension, revisions, and incomplete phrases.

Interiorized vs. exteriorized-Covert - avoidance, expectations of stuttering expectation of
fluency, motivation, starter devices, circumlocutions, and self-perception

They are aware of their stuttering and are embarrassed by it.

                                             Guitar-

Stuttering as a disorder of the neuromotor control of speech, influenced by the interactive
processes of language production and intensified by temperment and complex learning processes. Neuromotor control of speech is disordered because of interitance or injury has resulted in an inefficient or unstable cerebral organization. The neuromotor control of the children begins to show disruption as their language development in preschool years requires planning and production of larger and more complex syntactic units.

So-- Neurophysiological, psychological, social, and linguistic factors contribute to the onset and development of stuttering.         

                                    What is Stuttering?

                                           Bloodstein

The problem of defining a phenomenon is intimately bound up with the question of operations we use to measure it. What are the measurable dimensions
1. Frequency of Stuttering- number or percentage of moments of stuttering or of stuttered words or syllables
2. Mean Duration of Stuttering-the average duration of a stuttering block - 1 sec. In general one stutterer does not differ very much from another in the mean duration of blockages
3. Frequency of specified dysfluency types --Johnson 1959-61
interjections, part-word repetitions word repetitions, phrase repetitions, revisions,
incomplete phrases, broken words prolonged sounds.
4. Speech rate-oral reading rate in words or syllables per minute, Stuttering retards the speaker’s speed
5. Ratings of Severity- mild moderate, severe.

Can stuttering be cured?
Preschool
After puberty-will make only partial recovery

Variables distinguishing fluent and disfluent Speech
Dalton and Hardcastle (1977) Distinguishing fluent and disfluent speech p. 10 in your book

Core behaviors-
Repetitions,
Prolongations-sound continues but articulators stop
Blocks-audible and silent (respiratory, laryngeal, or articulatory)
With deve. of st. blocks grow longer and more tense; tremors

Research on core behaviors

1. Evidence suggests that part-word repetitions and whole-word repetitions and sound prolongations are the most common first signs of stuttering.

2. Research indicates that an average stutterer stutters on about 10% of the words while reading aloud. Mild stuttering 5% of the words; Severe 50% of the words

3. Duration- 1 second; rarely longer than 5 sec. 

Secondary behaviors are learned reactions to the basic core behaviors.

(a) escape-things a st. does to get out of the stuttering moment (eye blinks, head nods,
interjections)and
(b) avoidance behaviors-occur when a speaker anticipates stuttering-changes words, pauses,--postponements, starters

Feelings and Attitudes-
fear, embarrassment, shame and hostility negative attitudes about themselves, and their listeners
 

What we know About Stuttering?

1. Onset- any time during childhood-to puberty Most likely to begin bet 2-5

2. Prevalence- the degree to which a disorder is widespread--1%of the school children
world-wide can be considered stutterers May be a decline in stuttering after puberty so prevalence in adults --less than 1%

3. Incidence- an index of how many people have stuttered at some time in their lives 5%

The difference between the 1% and the 5% suggests that most individuals who stutter at some time in their lives recover from it.

4. Recovery without treatment=50%-80% will recover with or without professional treatment most before puberty. Some studies show much less recovery rate stating that some of the above were very mild young children 

5. Sex Ratio- 3 male to 1 female; 5:1 by the 5th grade;

Variability and Predictability of Stuttering-
Anticipation/Consistency and Adaptation

Anticipation: Stutters can anticipate which words they will stutter on
Consistency: They consistently stutter on the same words
Adaptation:  With repetition adaptation occurs and there is less stuttering with each reading; however, those words that continue to be stuttered on are the words stuttered on in previous readings.

Language factors- The loci of stuttering: People who stutter,  stutter more frequently on the following:
1. consonants
2. sounds in word-initial position
3. in contextual speech (versus isolated words)
4. nouns, verbs, adjectives, adverbs (verses articles, prepositions, pronouns, conjunctions)
5. on longer words
6. on words at the beginning of sentences
7. on stressed syllables

Preschoolers are different in their stuttering characteristics:
1.  more stuttering occurs on pronounds and conjunctions
2. Repretitions of whole words is frequent.

Fluency-Inducing conditions

speaking alone, when relaxed, in unison with another speaker, to an animal or infant, in time to a rhythmic stimulus or singing, in a dialect, while simultaneously writing, and swearing; speaking in a prolonged manner, with loud masking noise, while listening to delayed auditory feedback, shadowing another speaker speaking with reinforcement for fluent speech.  Studies suggest reduced demands may be needed because the brain organization for motor speech and language functions of adults who stutter may not favor rapid processing

Explanations regarding why these are fluency enhancing conditions

l. Stuttering has a Learned component, which is affected by external stimuli such as
communicative pressure;

 2.When neurophysioloical demands of speech motor control and language formulation are reduced, stuttering is reduced.

 3.Guitar-stuttering as a disorder of the neuromotor control of speech, influenced by the
     interactive processes of language production and intensified by complex learning processes

Summary of current knowledge about stuttering:

1. Stuttering is a disorder of childhood more common in males than females

2. there is evidence that both genetic and environmental factors play a part in its etiology;
Runs in families

3. No major personality difference between st. and nonst. have been discovered, although mild degrees of maladjustment seem to be fairly common among st,

4. May be subtle constitutional differences bet. st. and non st. but research has not revealed any organic abnormality that is a necessary and sufficient condition for st.

5. St. are often delayed in sp. and lang. and often tend to have early articulation diff.

6. St. is distributed in response to features of words that tends to make them difficult. according to past speech failure.

7. It varies in frequency from situation to situation in response to such factors as communicative pressure, awareness of oneself as speaker

8. We are able to identify certain types of disfluency--especially part-word repetition; rep.
of whole words and prolong. of sounds which tend to occur more often in the speech of children than non-st.

9. Evidence suggests that the speech repetitions of children are related to some type of difficulty with whole syntactic units to a greater extent than to difficulty with words.

Characteristics of stuttering behaviors - Bloodstein

1. Repetitions are different-insertion of the schwa

2. struggle to produce sounds - tremors, body movement,

3. can be manipulated under various conditions (repeated readings)- adaptation effect

4. can be distractible-to produce fluency

5. Have an internalized belief system about communication that differs from the perception of
others = victims.
*********
Differences between normally disfluent and incipient stuttering

Culatta- Normally communicating children hit a peak of disfluency usually between 2.5-4 yearsof age.

characterized by repetition of whole words and phrases with occasional interjections of
“uhs”,  “ers”, and “ahs”

disfluencies of incipient stuttering children are markedly different from those of their
normally disfluent counterparts.

children who go beyond simple repetitions and interjections to forced prolongations of sounds accompanied by signs of physical struggle in producing may be "incipient stutterer"

they begin to repeat parts of words rather than whole words, and frequency and duration of these episodes increase past normal expectations.

Pindzola and White (1986) summarizing current beliefs suggest that if more than 5% of a child’s speech is characterized by repetitions of sounds or words and more than 1% is abnormally prolonged, the child has left the boundaries of normal developmental disfluency.
 

Constitutional Factors
Differences between st. and non st.

Intelligence- both verbal and nonverbal intelligence is slightly lower in st. as a group.

--Studies suggest that stuttering might be linked to some inadequacy in linguistic and or motor process or both.

--Deficits in linguistic ability, motor ability or both increase the likelihood of stut.

--There is a higher incidence of st. in MR.

--Multiple intelligences approach may reveal ns

School performance- perform slightly below average in school may be attributed to fear of stuttering and/or deficit in language skills

Speech and Lang.

In general, research has found that other speech and language difficulties are more common among children who stutter than those who don’t.

--Studies have shown that children who st. have more difficulty with articulation.

--Research has repeatedly shown that st. have roughly two and a half times the incidence of articulation disorders as that found in non st.

--Some research suggests there may be subgroups of children who st. who have lang. or art. problems related to stuttering.

    Theories regarding speech and language deficits
a. some children with have difficulty with art,. or lang. will start to believe that speaking is difficult. Their anticipation of difficulty will lead to hesitation and struggle then to st. (Bloodstein)

b. Genetic: st. and defects in lang. and art all come from a common deficit, which might be passed on genetically

c. Art. or lang. disorders make recovery from st. more difficult. Children who st. and also have phonological or lang. differences are more likely to persist in st.

Anxiety and Autonomic Arousal-

St. are not more anxious than non-st; but during stuttering there are higher levels of arousal

Arousal and st. may be chained. Arousal makes st. more likely, st. produces a higher level of arousal.

Sensitivity- (little data)

Does inherited sensitivity make st. more likely or does years of st. make stutterers more sensitive?

Parents rated stuttering children as more sensitive than parents of non-st. children.

Sensory-motor Coordination

A.  Reaction time-  Slower in starting a stopping a sound such as "ahhhh"
Slower in reacting with respiratory and articulatory movements.

Extra time may be related to increased demands of linguistically meaningful stimuli. If a task is difficult and requires extra neuronal resources, other tasks have fewer neuronal resources at their disposal and must be done more slowly. Thus, slower reaction times in stutterers may result from difficulties in any or all of the three area: sensory analysis, response planning, or response execution.
 
B.   Central Auditory Processing-

May be a result of how st. hear themselves speak –auditory loop

Studies - more poorly on tasks requiring discrimination of small time differences in signals

Timing of incoming signals- Faulty timing would give rise to the st. poorer performance on central auditory tests.

Faulty timing of outgoing signals would result in st.

C. Cerebral dominance
Differences in auditory processing, language dev, speech motor reaction time, reaction time to linguistics, and delay in tracing auditory stimuli with speech motor responses may all be related to the organization of speech, lang. and auditory functions in the brains. People who st. may be using a less effective part of the brain for processing
speech functions. Left-for speech and lang. because it can process rapidly changing signals

--Research suggest that people who st. use their right hemisphere, which leads to intermittent breakdowns because the right hem. is not as adept as the left in processing the rapid transitions that characterize spoken lang. Right- for more slowly changing signals-music, environmental sounds, and intonation

--Adults who st. - more right hemisphere dominate for linguistic processing.  St. may be using a less effective part of the brain for timing speech

--When reading aloud- st. activated areas in the right hemisphere that were mirror images of the left hems. Areas used by non st.

--Rt. hemisphere activation included not only with speech-motor planning and execution but also in lang. processing areas; and activation is seen in both stuttered and fluent speech; In addition there is less activity in the left auditory language areas and greater activity in motor areas of cerebrum and the cerebellum.  Choral reading was associated with a reduction in the level of over activation in motor area for the st. group and normal levels of activation in their left auditory areas.

--Rt. hem is usually associated with emotional expression. This suggestion has implications for the onset of st. in childhood when many functions appear to have greater bilateral representation.. Fluency may be vulnerable to emotional disruption. If left hem is weak for speech, any neural resources may divert from left hem processing to the right hem. which is stronger. A finding of greater rt. hem. activation during stuttering could be a correlate of greater emotionality during stuttered speech.

Theory: supplemental motor area of the brain may be at fault and airflow missappropriation of neuronal space.  SMA is responsible for directing hemispheric traffic and regulating speech motor organization.

Studies of Fluent speech:

Even when fluent, on the average, st. have longer vowel durations, slower transitions bet. consonants and vowels, and delayed onsets of voicing after voiceless consonants. Theory: this may reflect delays in processing incoming and outgoing signals—of laryngeal, and art. muscle groups.  Some suggest: may be the mechanism functions at a slower rate.
As a group st. move some of their speech structures more slowly, even in fluent speech than non st;  Some studies show that st. excessively contract both the agonist and antagonist muscles of laryngeal and articulatory muscles groups; Some suggest slower movement are the result of heightened tension in all speech muscles.

Guitar position:
slower movements are the result of heightened tension in muscles having antagonistic functions for speech production. (Muscles that move the movement forward and those that hold it back are fighting each other) This accounts for: a. slowed movements in fluent speech, no st, when relaxed, sometimes stuttering worse than others.

Bloodstein. has pointed out that the differences between st. and nonst. have shown themselves to be neither nec. or suff. to create st.

As a group st. differ from nonst. on cognitive, linguistic, and motor tasks.

Guitar Three factors that put children at risk for st.

a.  constitutional predisposition for speech motor discoordination
b. developmental and environmental pressures
c. constitutional or environmental predisposition to develop excess laryngeal tension in

conditions of frustration or fear (different children react differently to frustration and have different tolerance levels.)

Constitutional Factors

Heredity-( page 23)

1. Relatives of st. are at greater risk for st. than are relatives of nonst.

2. Females appear more resistant than males to st.

3. Relatives of female stutters might be more likely to st.

4. Twin studies- higher concordance for st. in identical twins than fraternal twins.

5. Some identical twin pairs are discordant suggesting environment influences; adoption studies suggest that both heredity and environment may be important.

6. Some unknown factor appears to be inherited, creating a predisposition for st.

7. Environmental influences may trigger st. in children with the predisposition.

Single gene models:
mostly fits the data that includes very young subjects, many of who recover. Their st. is less complex form of the disorder.

Polygenic multifactorial model:
Subjects whose st. persists into adulthood; may inherit additional factors that increase the likelihood that st. will be chronic

Kidd studies are famous genetic studies

Theories:

Theories have been classified in several ways:

Guitar and peters- Constitutional/ Developmental/ Environmental

Culatta- Medical/Psychological/Manipulable Behavior Model

Nicolosi-anticipatory, and struggle behavior theory, breakdown theory, capacities and demands theory, cybernetic theory, learning theory, repressed need theory

Bloodstein-Theories that emphasize etiology, theories that emphasize moment of stuttering and theories that shift a frame of reference.

                             Anticipatory/ Struggle Behavior Theory

Stuttering occurs because the person believes that speech is difficult or that it will result
in failure
a. Primary stuttering theory - Van Riper- stuttering emerges from normal dysfluencies when a child learns to anticipate, avoid and fear speech or speech situations because of reactions by listeners

b. Diagnosogenic theory- Johnson- caused by misdiagnosis of normal dysfluencies in a child’s speech. (semantic theory of stuttering) 
Johnson:  The onset of stuttering may be a joint product of the parent’s high standards of fluency, the child’s unusual sound and degree of dysfluency, and the child’s proneness to react to either or both of these.  (pg 70)

c. Communication failure theory- Bloodstein- stuttering begins as a response to tension and fragmentation in speech, which is caused by continued or severe failures in communication under pressure. (pg. 72)

Bloodstein

1. Stuttering is a type of anticipatory struggle reaction.
2. Stuttering results from a disabling belief in the difficulty of speech
3. Beliefs that speech is difficult arise from situations that forces children to labor over their

    utterances or in some way establishes the idea that speech requires effort and care.
4. Parents may be concerned about other aspects of a child's speech besides fluency --ie delayed         development of speech, faulty articulation, cluttering, oral reading difficulty in the classroom

5. Stuttering may stem from almost any situation; Speech pressures- parental perfectionism,
    personality of the child, chronic recitation fright, trying to keep up with another, adult
    speech model whose speech is a matter of family pride.

                                      Breakdown Theory

Constitutional predisposition toward stuttering which is precipitated by psychosocial or
environmental stress

a. Cerebral dominance and handedness-Travis/Orton-There is a cerebral dominance; ambidexterity or a change in handedness causes disruption of smooth flow of nerve impulses to the speech muscles (created neuromotor disorganization and mistiming) (pg 39)
(New Version ) Geschwind and Galaburda-result of delay in left hemisphere growth during fetal development caused by a male related factor- excess secretion of hormone testosterone.

Why this affects speech and Language?-
According to Geschwin and Galaburda, various structures which evolve during embryonic development. are suited for speech and language. Specialized nerve cells develop which normally migrate to the structures in the left hemisphere, but if the hemisphere is delayed in development, the cells detect this and migrate to the right hemisphere, which is more developed but not ideally suited for speech and language. An explination of why some outgrow stuttering is that the plasticity of the brain may reorganize neural networks. 

b. Dysphemia and biochemical theory- West- stuttering is a symptom of illness, emotional or environment. stress and may also be the result of biochemical imbalance.
A recent chemical imbalance hypothesis is the increase in dopamine in the subcortical area. (Dopamine hypothesis)

c. Perseveration - Eisenson- an individual has an organic predisposition to motor and sensory perseveration - manifestation is stuttering

d. Laryngeal Dynamics - longer VOT and speech initiation times and voice initiation times under some circumstances

e. Heredity model - Kidd studies- stuttering is 3 times more likely to occur in families with 1st degree relatives who stutter than in the general population- People are born with a predisposition to stutter.

                                  Capacities and Demands Theory

Capacities/Demands Theory:Starkweather- capacity for fluency is not equal to the demands of the environment; the demands of the child’s environment exceed the child’s capacity to produce fluent speech. The demands may be internal and linked to increasingly sophisticated language development or may be external from and environment that demands more fluency than the child can produce. (pg 73)

Reduced Capacity for internal modeling (inadequate neuronal space to make sensori to motor transfer)
Nielsons- (Although Guitar and Peters place this here, it also may be considered a cybernetic theory of stuttering.) There is a deficit in the persons ability to make and use Inverse internal models of the speech production system. the child has a sensory-motor model for speech (it inverts sensory targets into motor commands) Children plan an utterance based on what it should sound like. They generate the motor commands. The motor commands are sent to the muscles, which are stored in the brain as models. The actual speech is compared to the model expected amd refined/updated if needed via cortico cellebeller pathways.  The child has a weakness in making transformations between what they want to say and the motor movements required to say
them: the sensory to motor and motor sensory transformation. If the demands are not great, stuttering doesn’t occur because the child can compensate for the weakness. (pg 41)

Stuttering as a Language Production Deficit

Covert repair hypothesis:
Stuttering reflects an impairment in some aspect of languae production [the planning and assembly of language units (such as phonemes) that occur before speech production].  Most common stuttering disfluencies all are the result of correcting or "repairing" phonological (rather than semantic, syntactic, or lexical errors detected in thephonetic plan before articulation (pg 43)

Cybernetic Theory of Stuttering

Cybernetic Theory Fairbanks, Mysak, Lee and Black, Sutton and chase, CherryBased on the servomechanism feedback model in which the sensor is the ear, the effector is thevocal organs and the motor innervations and the controller is the function of the brain- there is a breakdown in the models efficiency at any level

Disorder of Timing  There is inappropriate localization of some speech/language functions in the right hemisphere and is manifested in an inability to create precise timing patterns to produce speech efficiently. (pg 40)
Kent- The brain must coordinate proper timing programs. The Central timing device must regulate the rapid left hemisphere aspect of segmented speech and the slower right hemisphere aspect of prosody. Emotion may also disrupt timing. There may be interference by the right hem. during increased emotion.

Learning Theory

Stuttering is learned.

A. Approach Avoidance (Sheehan; Perkins)
1.Stuttering is a result of a conflict between opposing drives - to speak or refrain from

    speaking
2. The stuttering Block is the involuntary outcome of other learned approach-avoidance drives
    and not itself a learned behavior

B. Conditioned Disintegration Theory-Brutten and Shoemaker - also called the Two- Factor Theory of Stuttering.
1. Stuttering is the involuntary disruption of speech resulting from negative emotional
    responses that are classically conditioned;
 2. secondary char. (escape and avoidance) are

    instrumentally conditioned

C. Instrumental Avoidance Act Theory -Wischer- Stuttering is an acquired response motivated by
the learned drive of apprehension about normal dysfluencies

D. Operant Behavior Theory Speech is a behavior under operant control of positive and negative reinforcements; Stuttering is maintained on a complex schedule of reinforcement (Azrin, Flanagan, Goldamond, Martin and Siegel, Shames and Sherrick

                            Neurotic Theory - Repressed Need Theory-

Freud- Stuttering is a neurotic behavior-a denial of basic physiological needs results in a
behavior, including stuttering, (suggests a stuttering personality)

Developmental and Environmental Influences

Developmental

Brain must share resources because of the many demands placed on it. The child’s nervous system has less processing capacity to share than the adults’

1. Physical Development

a. physical growth may compete with speech for available neuronal resources
b. physical growth may require new adjustments to to the servomechanism (sensor-to motor and motor to sensory transformations)--physical growth of the mechanism requires new sensory to motor and motor to sensory
adjustments.

2. Cognitive Development: Cognitive processes include: perceiving, reasoning, imagining and problem solving
Cognition and stuttering relationship- Some aspects of cognitive development may compete with speech and language development for neuronal resources

3. Social and emotional
a. Interference between limbic system: neural timing for speech may be interfered with
b. Stress- reaction from others; family stessors; threats to security (birth of a sibling)
c. Development of self consciousness- stages of development include: independence (separation from     parents)  social emotional traits can change with time ( may predict chronicity)
d. Psychological adjustment - normal

4. Speech and Language Development

Rapid acquisition of language competes with available resources for speech production; If he already is slow in language, needs more cognitive effort to produce it, less available for motor aspect of speech. As language complexity is increased, increased disfluencies until language is mastered with automaticity. Automaticity requires less neuornal sources.

                                      Environmental Factors

Factors outside the child (attitude, behaviors, and events that occur in the home)
Pressures to speak--Speak at rates beyond capacity ( in response to listeners impatience)
1. Parents- Some findings:
--Mothers of st. are more critical, protective, domineering
--Parents- higher standards, expectations, more perfectionistic; more anxious parents may speak more rapidly

Bloodstein: parents transmit competitive pressure for achievement or conformity

Other studies show different findings. Anything placing pressure on the family places additional pressure on the child.

Speech pressures- parental perfectionism, personality of the child, chronic recitation fright, trying to keep up with another, adult speech model whose speech is a matter of family pride.

2. Speech and language

Demands made by syntax may deplete resources for other levels- prosody; Stuttering may increase when an individual uses longer words, less frequently occurring words, more information bearing words and longer sentences or linguistically competes sentences

Rapid speech rates, interruptions (stress) simultalk

3. Live events- Changes in life situation, which cause stress
 
 To Parents:

1. Don’t interrupt- give him a chance to talk
2. Slow down your speech
3. give him your undivided attention
4. show no reaction to his stuttering moments
5. Don’t tell him to stop and start over
6. Dont turn away from him after punishing him
7. Remove all unnecessary pressures
8. Do not demand that he perform for others
9. Don’t finish sentences for him
10. Prepare him for events, which cause excitement i.e. Christmas
11. Reduce situations, which cause excitement.
12. Reduce communication stress felt by child
13.  No attention directed toward dysfluency

Types of Pressures:

1. Listener loss

2. Interruptions

3. Competition for the floor- reducing impatient listeners

4. Cross examination kind of questioning

5. Demands to perform

6. Demands for confession

7. Talking under conditions such as guilt, fear, anger, or when fatigued or distracted

8.  Parents must be taught to speak slow and simply as models

    a. Lengthen pauses

    b. Prolong vowels

    c. Shorter sentences simpler sentences

    d. Identification and elimination of pressures

9.   Good days - provide many opportunities to talk; Bad days - do non-talking activities

10.  Talking by way of dolls, masks, animals- encourage fluency

11.  Reinforce fluency; immediately grant attention

Others:
1. Be a good speech model
2. Eye contact
3. Want to talk- don’t turn away
4. Reassure- we all have problems
5. Keep calm
6. Don’t interrupt him
7. Don’t react to struggle
8. Learn to expect - never say words for him
9. Don’t call stutterer- don’t label
10. Don’t convey he’s doing something wrong bad
11. Don’t ask him to perform
12. Rephrase what he’s said (tends to slow him down)

                         Danger signs (Video from the Speech Foundation)

1. Multiple repetitions
2. Schwa vowel
3. Prolongations
4. Blocks
5. Tremors
6. Pitch rise
7. Struggle and Tension
8. Moment of Fear
9. Avoidance
10. Respiration Irregularities

 
Chapter 4
Review of the research findings:
1.  appears in children 2-5
2.  appears in all cultures
3. Earliest signs:  primarily repetitions of single syllables. Prolongations and blocks in some children
4.  more freuently in boys than girls
5.  most frequent recovery in girls
6.  recovery rate 80%
7.  Development of stuttering:
    a.  for those who do not recover from the earliest signs at about 4 years, frequency and duration of stuttering increases, secondatry behaviors develop and negative feelings and attitudes develop
    b.  Persistant stuttering in older children, adolescents and adults occurs most frequntly as partword repetitions, prolongations, and blocks at the beginnings of sentences
    c. Adults
        can anticipate words they will stutter on
         are consistent in their loci of stuttering
        become fluent under conditions of adapation
         become fluent under certain conditions
8.  Group differences:
    a.  slightly lower on IQ tests
    b.  more at risk for language and articulation
    c. perform poorer in school
    d.  slower reaction times
    e.  poorer at tasks of CAP
    f.   slower movements of their articulations even when fluent.
9.  clinical observations:
    stuttering gets words during periods of cognitive, linguistic, and physical growth
    stress of social-emotional developemnt may exacerbate stuttering
    environmental stresses are associated with the onset and aggravation of stuttering

10.  Many st. are within the normal range in terms of intelligence, language, articulation, and                             sensory-motor coordiation
    Stuttering waxes and wanes under influences of fatigue, health, and self-confidnece
    Thus, there are subtle differences in neurological functionaing that vary from moment to moment and day to day.

There are two biological predispositions for stuttering:  Atypical neural organization and temperament.
Aytypical Organization of neural activity for speech and language processing
Research:
    a.  Less left hemisphere processing of speech and languae in st than in non st.
    b.  St. tend to use more right than left hemispheric pathways or may process in damaged left hemisphere structures that result in less efficient functioning. 
    In general, individuals who stu. do not have the well-organized and efficient functional neural networks for speech and language. Because processing is less efficient, st. need more time, more resources or more stimulation to work synchronously.  In addition, performing multiple tasks in the same hemisphere may cause interference.  Interference of speech processing by competing emotional, cognitive, an motor activities affect the wide variability of fluency.

Temperament
Temperament may explain why some begin to st. and quit, why some start with easy st. which develops into persistent st. with tension, and why others begin st. with tension.
Kagan:  some children inherit a temperament that makes them more reactive to unfamiliar, threatening, or challenging situations.  Sensitive children manifest their reactivity by generating higher levels of physical tension, particularly in laryngeal muscles when speaking in unfamiliar or threatening situations.

Kinsbourne:  Emotional regulation is lateralized.  Emotion in the right hemisphere results in avoidance, withdrawl, and arrest of ongoing behavior (arrest, withdrawal and avoidance- core behaviors)
Left hemisphere: Emotions result in the opposite:  approach, exploration, and release of ongoing behavior.  Temperament sensitive children are right dominant for emotion.
Gray:
Tension is part of a bilogically based response in human. When frustration or fear are elicited, the response is governed by behavioral inhibition system which increases arousal, attention and inhibitory responses (freezing, light or avoidance - core behaviors) or forms of inhibitory responses.
Susceptibility to conditioning: children who react to disfluencies with tension because of a sensitive temperament may also be more susceptible to fear conditioning and conditioning tension responses to speaking situations (both tension and fear are produced by the amygdala).

Interaction with developmenal factors
    a.  physical, cognitive, emotional and linguistic domains may compete for reasources and affect the child's capacity to handle the demands.
    b.  Girls have more widely distributed neuroal activation patterns for languaea and so stuttering is less likely in girls
    c.  Temperament: more aware, more tension

Interaction with environment

1.  Slower speech rates, fewer interruptions may foster neurological adapations (less interference with emotions, less reactivity from temperament), less cognitive demands.
TX
    a.  control speech/language demands
    b.  Reduce frustrations causing tension
    c.  Slow speech, increase fluency, reduce fears of talking
    c.  Confront fears, reduce tension.

What about when genetic transmission doesnt appear to be present?
1.  Some family members inhereit only one factor and the other family member inherits the other.
2. Environmental factors that affect fetal dev.

How does Guitar view the expression of  the common signs?
Easy st.  from neural inefficiency
Tnesion from the frustraton and fear that stem from difficulty talking
Sudden onset-emotionally difficult period or traumatic stress
Neuroplasticity permits reorganization of neural pathways
Uninhibited temperament is an important predictor of recovery

How does Guitar's view support the development of stuttering?
Development of stuttering is determined by biological responses of the child to fear and frustration and to conditioning to which a child prone to chronic stuttering may be sensitive.

How does Guitar account for stimuli that reduces st?
Conditions provide more time, some organizing to speech, reduced stress, reduced reactive activity.

How does Guitar account for group differences?
Children who stu. will have some inefficient neural organization.  Those showing group differences probably have other difficutlies (articulation; sensory motor problems) They may have more anmalies in neural organization and are more likely to show the goup differences.

Learning factors:
definitions: 
Classical conditioning:  Stimulus substitution; Two stimuli occur in succesion.  The first is the unconditioned stimulus (and evokes a response) and the second is the stimulus which will become the conditioned stimulus to evoke the response after being paried with the unconditioned stimulus for a sufficient amount of time (Pavlovian conditioning)

Instrumental (operant) conditioning:  The examiner waits for a response to occur spontaneously and immediately afterwards rewards (reinforces) or provides a stimulus which will subsequently condition the response to occur purposefully (to receive the reward) Skinnerian conditioning.

Role of Conditioning in stuttering:

1st- excessive repetitions and prolong. are a result of interactions of constitutional, developmental and environmental factors

2nd. excessive rep. and prolong. create frustration which triggers reflexive responses of
increased muscle tension and rate of repetition.

The reactions to frustration form the unconditional responses (tension) which are classical conditioned to speech

Bad situations causing negative emotion (UCS) + Easy stuttering (NS) = tension (tense stuttering (UCR)

Easy stuttering becomes a conditioned response (conditioned to produce tension) and becomes tense stuttering

[easy stuttering is paired with frustration which causes tension so now easy stuttering becomes tense stuttering]

Spread of stuttering:
Easy stuttering (CS)(in that it is conditioned in that it produces tension) + words, people,
and situations (NS) = tense stuttering associated with words/ people/ situations (CR) SPREAD OF STUTTERING
a. Words/people/situations (CS)--conditioned to produce tension = tense stuttering CR
b. Escape responses are instrumentally conditioned


See picture page 91 for classical conditioning
See picture 93 for classical condition and stuttering
Spread of conditioning pg. 96
Tense stuttering paired with words/people/situaitons --  produces tension 

Learing is viewed as the storing of patterns of connections in memory.  The stimuli associated with what is learned is also stored as part of the pattern that encodes the event.

Instrumental conditioning:
Positive reinforcement- increases behavor
Punishment decreases a behavior
Negative reinforcement- increases a behavior via relief from a negative stimulus
Shaping: to gradually change a behavior into a desired behavior.

Principles in instrumental conditioning
1.  The strenght of the reward or punishemnt is important
2.  Immediate reinforcement is important
3.  Frequency of reinforcement is important (variable ratio is the most resistant to extinction
    a.  fixed ratio: reward after every so many responses
    b.  variable reward varies
4.  Without reward the behavior becomes extinct
5.  Stimulus generalization- behavior learned in one situation occurs in a situation that is simular but not identical with the orginal
Avoidance conditioning:
Avoidance arises from instrumental and classical condition (may explain relapse)

How can we extinguish stuttering?
Maintain fluency in tension provoking situations.  Establish a heirarchy and move from situations that produce the least amount of stuttering to those that are very difficult; learn how to remain fluent in the midst of distractors
Produce speech without tension using fluency initiating gestures

Chapter 5

Levels of Stuttering

Borderline Stutterer

Underlying Processes-

1.  Guitar -believe that physiological sources play more of a role in the onset where as
conditioning processes play more of a role in st. dev.

2.  Guitar believes borderline st. is the result of constitutional and environmental
factors.--Cerebral organization; and envirnm./developmental pressures

3.  2-4-explosive language growth; security needs;

4-5-developmental demands slack off; but envr. stress and predisposition; and demands the child places on himself may continue--

Beginning st.

1.  Tension; and more repetitions. at first only when excited or stressed; then becomes intolerant and impatient w/ st. so he begins to use escape behaviors.
2. Fewer periods of fluency.
3.  With tension, struggle increases. --st. spread to other situations through instrumental and

classical conditioning.

Core-
Rep. rapid and irreg.
Schwa vowel
Increase tension-pitch rises
prolongs sounds that were repeated.
First blockages appear.

Secondary behv..
begin to demonstrate escape behaviors using fillers and starters.
Feelings-annoyed, frustrated, helpless, and embarrassed

Underlying Process
1.  classical and instrumental conditioning influences the dev. of st.
2.  Behavior is becoming chronic - tension and rate inc.
3.  Extra muscular effort when he anticipates difficulty
4.  Incre. tension in an effort to control the repetitions.
5.  Inc. speed of repetitions- product of pressure as he becomes aware of the time it takes for himto talk
One major factor underlying beginning st. is the child’s inherent sensitivity to stress whichmay easily result in the emotion of frustration, triggering a tension response. Then itspreads. Then the secondary behaviors are learned through operant condition.

 
Characteristics of Intermediate Stuttering-

1. Fear / Avoidance on sounds, words, situations
2. Withdraws
3. Circumlocutions
4. Changing words (substitutions)
5. Postponements
6. Most frequent core behavior is the block because of increased tension
7.  Tension can occur anywhere along the vocal tract where contact is made
Secondary behavior- more complex than beg. st.
a. Avoids words, sit, uses starters
b. Feeling-Attitudes: negative feelings of st.
1. looks away
2. avoidance

Underlying processes- classical and instrumental conditioning
1. learning primary factor- much learning has taken place

2. Self concept has been developed
3. Reality of his perceptions must be tested.

Characteristics of age for the intermediate stuttering problem
1. Individual can take responsibility for treatment
2. Physical concomitant behaviors
3. Covert stutterers
4. Avoidance behaviors affect jobs, social activity and friends
5. Evaluate listener’s reaction w/o really knowing because they aren’t’ really looking (reality of his perceptions of his listeners must be tested

Advanced Stuttering-

1. Long history of stuttering
2. Self-image is established- he thinks of himself as a stutterer;
3. His activities, friends, job are influenced by the fact that he thinks of himself as a
stutterer

Characteristics-
see pg 104
1. Most frequent core behavior is blocks
2. Complex patterns of extensive avoidance (words, situations) behaviors and escape behaviors
3. Emotions of fear, embarrassment, and shame are very strong
4. Negative feelings about himself; he feels frustrated, helpless.

Underlying processes:
1. Years of practice with conditioned habits (patterns of tension, escape avoidance
2. Negative self concept is established therapy-
3. Test reality of his perceptions.
4. Produce easy stuttering to reduce fear response of stuttering
 
 
 
 
 
 
 
 
 

 

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