LANGUAGE BASED DYSFLUENCY

Maliha Nizam

Rahat Umer

Shumaila Akhtar

Asma Agha

Yasmeen Jamil

Wajeeha Fatima

INTRODUCTION OF DYSFLUENCY

Maliha Nizam

STUTTERING

• Stuttering is a disruption in the forward flow of speech that is typically accompanied by physical tension, secondary behaviors, avoidance of communication, and/or negative reactions on the part of the speaker.

TYPES OF STUTTERINGDisruptions in the forward flow of speech may consist of:

• Repetitions: repeating of a syllable, sound, word, or phrase (e.g., “li-li-li-like this”)

• Prolongations: holding onto a sound for an extended period of time (e.g, “llllike this”)

• Blocks: no sound is produced then a “burst” of tension is released when the speaker if able to vocalize (e.g., “----like this”)

• Interjections: extra words (e.g, “um, uh, like”)• Revisions: speech is revised during and utterance (e.g., “I

have to go…I need to go to the store.”)

WILL A YOUNG CHILD OUTGROW STUTTERING?

• Many children between the ages of 2-5 go through a normal period of disfluent speech as their expressive language develops.

• This is a normal part of speech and language development for most children.

• While many children recover from periods of normal dysfluency, children are far less likely to recover from stuttering without intervention.

WHAT IS THE DIFFERENCE BETWEEN NORMAL DYSFLUENCY AND STUTTERING?

• Normal dysfluency tends to consist primarily of whole-word and phrase repetitions.

• Children may also exhibit a higher number of speech interjections as they develop their language formulation abilities.

• Stuttering typically consists of speech dysfluencies along with tension, struggle, secondary behaviors, or negative reactions to dysfluencies (e.g., frustration).

WHAT IS THE DIFFERENCE BETWEEN NORMAL DYSFLUENCY AND STUTTERING?

• Risk factors for young children (between 2-6) include a family history of stuttering, male gender, presence of other speech/language deficits, disfluent speech that has persisted for 6-12 months or more, or negative reaction to dysfluency.

• Children with any of the above risk factors should be evaluated by a speech-language pathologist.

WHAT ARE TREATMENT OPTIONS FOR PEOPLE WHO STUTTER?

• For younger children (ages 2-6), treatment is likely to include a combination of indirect (environmental modifications) and direct (teaching the child to modify his speech) treatment.

• For this population, the ultimate goal is typically to eliminate stuttering or reduce it to a mild level.

• For older children (age 7 and above) and adults, the goals of treatment shift to successful management of stuttering.

WHAT ARE TREATMENT OPTIONS FOR PEOPLE WHO STUTTER?

• This may include teaching strategies such as speech modification and stuttering modification strategies, increasing knowledge of stuttering, and reducing negative reactions to stuttering.

• The ultimate goal for older children and adults is to ensure that the person who stutters has the ability to manage their stuttering so that it does not interfere with their life or prevent them from communication with people or participating in social situations.

WHO CAN HELP?• It is important to remember that parents do not cause

stuttering. • Still, there are several things you can do to help your

child learn to speak more fluently. • Parents of young children can help by:

(i) providing a model of an easier, more fluent way of speaking,

(ii) reducing demands on the child to speak, particularly demands to speak fluently, and

(iii) minimizing the time pressures a child may feel when speaking.

DIFFERENCE BETWEEN NORMAL LANGUAGE AND DYSFLUENCY

Shumaila Akhtar

NORMAL SPEECH AND LANGUAGE• Reach major milestones in predictable stages by 6

years of age. The exact pace at which speech and language develop varies among children, especially the age at which they begin to talk.

• Although speech and language continue to develop through adolescence, children usually

• Communication skills are often categorized as receptive language and expressive language. Receptive language is the understanding of words and sounds. Expressive language is the use of speech (sounds and words) and gestures to communicate meaning. 

• Developmental milestones can be described according to age.

BIRTH TO AGE 1:• Babies start to process the communication

signals they receive and learn to vary their cries to communicate their needs. During the first months of life, a baby is usually able to recognize his or her mother's voice and actively listen to language rhythms. By 6 months of age, most babies express themselves through cooing. This progresses to babbling and repeating sounds.

• By the first birthday, babies understand and can identify each parent, often by name ("mama," "dada"). They repeat sounds they hear and may know a few words.

Age 2:• After the first birthday through age 2, a toddler's speech and

language foundation grows rapidly. During that time, 1-year-olds learn that words have meaning. They point to things they want, and often use one- or two-syllable sounds, such as "baba" for "bottle." By age 2, children usually can say at least 50 words and recognize the names of many objects, including those in pictures. They also understand simple requests and statements, such as "all gone.“

• They usually can name some body parts (such as arms and legs) and objects (such as a book). Not all their words are intelligible; some are made-up and combined with real words. In addition to understanding simple requests, they can also follow them (such as "put the book on the table"). They should be able to say at least 50 words. They usually can say about 150 to 200 words, some of which are simple phrases, such as "want cookie." Pronouns (such as "me" or "she") are used, but often incorrectly.

• Some children are naturally quieter than others. But a child who consistently uses gestures and facial expressions to communicate should be evaluated by a doctor. These children are at increased risk for having speech problems.

Age 3:

• More sophisticated speech and language develops from ages 3 through 5. By age 3, most children learn new words quickly and can follow two-part instructions (such as "wash your face and comb your hair"). They start to use plurals and form short complete sentences. And most of the time their speech can be understood by others outside of their family. "Why" and "what" become popular questions.

Age 4:

• Most 4-year-olds use longer sentences and can describe an event. They understand how things are different, such as the distinction between children and grown-ups. Most 5-year-olds can carry on a conversation with another person.

LANGUAGE DISFLUENCY

• A dysfluency is a break or interruption in otherwise normal speech. Depending on the degree of dysfluency involved, it may slip by without notice, or make someone hard to understand. In some cases, dysfluency is also combined with stuttering, which can make someone almost unintelligible, and it can also be very frustrating for the speaker. Almost everyone uses dysfluencies in their speech

LANGUAGE DYSFLUENCY

• Dysfluency can also take the form of sentence repair, as someone recognizes that an error has been made and backtracks to fix it. Humans are surprisingly good at fixing errors on their own, so sentence repair can draw attention to an error which might have otherwise slipped past without notice. Sentence repair often involves a partial repeat, as in "the cats wants to sit on lap...er, rather the cat wants to sit on your lap."

FACTORS OF DYSFLUENCIES

Rahat Umer

• ND is the result of an identifiable neuropathology in a speaker with no history of fluency problem prior to the occurrence of the pathology.

• Often speech dysfluencies appear at onset, or progressive disease.

• Neurologic dysfluencies are often different in form from those presented by stutters.

• Like articulation dysphensis and dysprosody disorder

• The different dysarthrias that can result from the neuromotor speech system often include dysfluencies and other communication deficits like articulation. dysphonias and dysprosody, disorder which occur as infrequently in stutterers as they do ii: the general

• The aphasic patient who experiences dysnomia or dementia may display highly disfluent speech while searching for words. Interjections, unusual pauses, and circumlocution are all probable.

• Reports that drugs which affect the basal ganglia may affect speech fluency. She report three studies that tend to link disfluent behavior with concurrently administered medications in clients with no previous history of disfluent speech.

• Psychogenic dysfluencies may be grouped into three categories.

• Emotionally based dysfluencies• Manipulative dysfluency • Malingering• Language delay

This is a dysfluency that is attributed to the development of linguistic sophistication. The main root of the problem here would be language problems, which would require language based therapy rather than fluency-based therapy.Mixed Fluency FailuresThese are fluency failures that are characterized by overlapping causative factors. Speech pattern observed is the result of a blend of two or more factors/dysfluency.

ASSESSMENT Of LANGUAGE BASED DYSFLUENCY

Asma Agha

Introduction

• Individuals suspected of having a fluency disorder are referred to a speech-language pathologist (SLP) for a comprehensive assessment.

• A thorough assessment focuses on components known to accompany fluency disorders (e.g., behavioral, cognitive, and others).

• Assessment is individualized and based on the person's communication environment.

Comprehensive AssessmentA comprehensive assessment typically includes

relevant case history, including– medical history;– general development;– speech and language development, including frequency of exposure

to all languages used by the child and the child's proficiency in understanding and expressing himself/herself in all languages spoken;

– family history of stuttering or cluttering;– description of characteristics of dysfluency and rating of severity;– age of onset of dysfluency and patterns of dysfluency since onset

(e.g., continuous or variable) and other speech and language concerns;

– previous treatment experiences and treatment outcomes;– information regarding family, personal, and cultural perception of

fluency;

Comprehensive Assessment consultation with family members, educators,

and other professionals, including their observations of fluency variability (when dysfluencies are noticed most and least) and impact of dysfluency;

real-time analysis or analysis based on review of a taped speech sample, if provided by a parent or teacher, demonstrating representative dysfluencies beyond the clinic setting;

Comprehensive Assessment

• review of previous evaluations and educational records;

• assessment of speech fluency (e.g., frequency, type, and duration of dysfluencies; presence of secondary behaviors; speech rate; and intelligibility) in a variety of speaking tasks (e.g., conversational and narrative contexts);

Comprehensive Assessment

• stimulability testing in which the child is asked to increase pausing and/or decrease speech rate in some other way-a reduction of overall rate of speech typically assists with a reduction in cluttering symptoms;

• assessment of the impact of stuttering or cluttering-including assessment of the emotional, cognitive, and attitudinal impact of dysfluency-for information concerning speaking frequency and socialization;

Comprehensive Assessment

• assessment of other communication dimensions, including speech sound production, receptive and expressive language development, pragmatic language, voice, hearing, and oral-motor function/structure;

• determination of individual strengths, coping strategies, and available resources that may facilitate the treatment process.

Assessment Evaluation

• diagnosis of a fluency disorder, including differential diagnosis of type of fluency disorder (stuttering, cluttering, or both) and between fluency disorder and reading disorders, language disorders, and/or speech sound disorders;

• descriptions of the characteristics and severity of the fluency disorder;

Evaluation

• judgments on the degree of impact the fluency disorder has on verbal communication and quality of life;

• determination if the child will benefit from treatment;

• determination of adverse educational, social, and vocational impact;

Evaluation

• recommendations for treatment;

• consultation with and referral to other professionals as needed;

• ongoing education about stuttering or cluttering for family, school personnel, and other significant people in the child's environment.

“The measurement of attitudes and attitude change

are essential parts of successful treatment!!”

CONSIDERATION

Yasmeen Jamil

CONSIDERATION:

• Frequency of dysfluencies

• types of dysfluencies

• duration of dysfluencies

• secondary behaviors

• high risk environmnet

• high risk family history

• high risk fluent speech

DECISION ABOUT TREATMENT:

• Decision 1: Explore your level of confidence in treating stuttering

• Decision 2: Establish the long-term goal of treatment

• Decision 3: Choose a philosophical approach to treatment

• Decision 4: Design a system of documentation

• Decision 5: Consider factors over which you have minimal control

• Decision 6: Establish realistic short-term goals

• Decision 7: Examine reasons for slow progress or failure to achieve goal.

• Decision 8: Examine the clinician’s role in success of intervention

• Decision 9: Determine whether stabilization of progress has occurred.

• Decision 10: Examine motivations for termination of treatment

TREATMENT

Wajeeha Fatima

OBJECTIVES OF THERAPY:

• Help child feel comfortable talking about stuttering

• show how stuttering can be changed to make talking easier

• teach child to ‘slide’ into difficult words

• teach child to ‘keep their voices going’ once they begin a sentence

PROCEDURE FOR THERAPY:• Reduce avoidance by reinforcing stuttering• child is reinforced for communicating

regardless of fluency• child is reassured that

speech is sometimes hard for everyone but that it is no big deal to have trouble once in a while

TREATMENT APPROACHESTreatment approaches for preschool children who

stutter include: INDIRECT: Indirect treatment focuses on counseling

families about how to make changes in their own speech and how to make changes in their  child's environment. These modifications are used to facilitate speech fluency and may include reducing communication rate, using indirect prompts rather than direct questions, and recasting/rephrasing to model fluent speech.

Direct

Direct treatment focuses on changing the child's speech in order to facilitate fluency.  Direct treatment approaches may include speech modification and stuttering modification strategies to reduce dysfluency rate, physical tension, and secondary behaviors

• Operant• Operant treatment incorporates principles of operant

conditioning and uses a response contingency to reinforce the child for fluent speech and redirect disfluent speech (the child is periodically asked for correction). With this approach, parents are trained to provide verbal contingencies based on whether a child's speech is fluent or stuttered In this way, positive reinforcement is used to increase or strengthen the response of fluency (the desired behavior). Operant approaches operate within a framework of stuttering as learned behavior

Multifaceted treatment goals

provide family with accurate information help family modify environmental

factors that may stress child’s fluency help family learn new ways to

communicate to better match child’s current level of development

Multi-modal procedures

– identify successes and problem areas– choose a target area– brainstorm ways to address the target– practice the skill– utilize the skill with the child in the

clinic– carry over the skill to home

Utilize a Fluency Enhancing Model (FEM) to Meet Child’s Needs

Facilitate a rate reduction in the child’s speech

Reduce other potential demandsSet up talking time rules

Support/expand the child’s positive image of self

Preschool child who stutters

• Intervening with the child’s family

• A comprehensive treatment approach for school-age children and adolescents includes multiple goals based on individual needs, focused on increasing fluency as well as other goals, such as "increasing acceptance of stuttering and of being a person who stutters, reducing secondary behaviors, minimizing avoidance, improving communication skills, increasing self-confidence, managing bullying effectively, and ultimately, minimizing the adverse impact of stuttering on the child's life"

• PLANNING TREATMENT OF STUTTERING FOR YOUNG CHILDREN

• Disfluent behavior becomes more complex as fear of speaking, anxiety, and resulting avoidance increases. Similarly, communication apprehension and shame may develop as the child experiences greater difficulty with communication. Treatment may include reduction in the child's and others' negative reactions to stuttering For example, clinicians may use treatment strategies to reduce bullying through desensitization exercises and by educating the child's peers about stuttering. Many of the treatment options are used in combination for optimal outcomes. For example, counseling a student to accept or tolerate embarrassment can facilitate the desensitization needed to reduce the use of word avoidance. As word avoidance decreases, the teen is better able to communicate effectively, and, as fear reduces, the resultant reduction in physical tension and struggle enhances observable fluency.

Additional strategies that may be useful

– modeling normal dysfluencies for child

– teaching child to use slow rate

– More normal volume

– Easy vocal onset