با تشکر ویزه از استاد گرامی: گردآورندگان: جناب آقای برزگر جناب آقای حسینی نسب جناب آقای خدادوست جناب آقای قاسم پور جناب آقای معرفتی جناب آقای امیری سرکار خانم شفیعی سرکار خانم موذنی جناب آقای شفیعی با تشکر ویزه از استاد گرامی: سرکار خانم آقا رسولی

STUTTERING

What is Fluency Disorder? Some questions What is Fluency Disorder? What is stuttering? 3

Two essential characteristics: Fluency Disorders Two essential characteristics: Disturbance in the normal fluency and timing patterns of speech Disturbance in social communication, academic performance, or occupational achievement

What Is Stuttering? An impairment of speech and language production, typically characterized by interruptions in the forward flow of speech (“speech disfluencies”)

(Developmental) Stuttering Neurogenic Stuttering Type of Stuttering (Developmental) Stuttering Neurogenic Stuttering Psychogenic Stuttering 6

Features of Stuttering Core Features Repetitions of Sounds Syllables Words Phrases Prolongation of Silence (blocks or tense pauses) 7

Features of Stuttering Additional Features Frequent use of interjections (e.g. ‘um’,’ah’,etc) Unwanted movements of the body e.g. Facial grimaces Eye blinking Jaw jerking Head movement Muscle contractions Arm and foot movements 8

Features of Stuttering Additional Features Feelings of Fear Embarrassment Shame Avoidance of Feared words Difficult speaking situations (telephone, public speaking) Social interactions Certain types of employment, recreation, etc 9

How Does Stuttering Develop? Typically begins between ages 3 and 5 As the disorder progresses, children are likely to develop reactions to stuttering... Tension and struggle in their speech musculature More advanced types of speech disfluencies Concern or anxiety about their speaking abilities These reactions can have profound social, emotional, and educational consequences

Neurogenic Stuttering Follows a identified neurologic event Stroke Head injury Onset of neurological disease Some Features Part-word or phoneme repetitions No patterns related to word type Not restricted to initial words No syllable stress effect Lack of anxiety or secondary symptoms Less responsive to fluency-enhancing conditions 11

Psychogenic Stuttering Some Features Sudden onset, typically related to some event Repetition of initial or stressed word Fluency enhancing effects not observed No periods of stutter free speech Initially no interest in problem Stuttering in response to emotional trauma or stress 12

Prevalence: 1 in 100 persons Prevalence and Incidence Incidence: 5 in 100 persons Males are affected at a higher rate than females (approximately 3:1) Prevalence: 1 in 100 persons Affect children between the ages of two and 10 years at the highest rates

Causes and Risk Factors For the majority of children, stuttering begins for no apparent reason Hard to identify, because results from complex interaction of two types of factors: Predisposing: individual’s constitutional factors that make him susceptible to a fluency disorder (70% of likelihood) Precipitating: developmental and environmental factors that can worsen stuttering (30%)

Family history: tendency to run in families, and genetic link seen in twin studies Gender: boys are more likely to develop a fluency disorder and slower to recover Processing ability: underlying problem with linguistic processing (demand and capacity model) Motor-speech coordination: difficulty in coordinating and timing the motor activities required for fluent speech Predisposing Factors

Precipitating Factors Age: average age of emergence is 3 years for boys and 2.5 years for girls Development stressors: Stressful adult speech models: children exposed to adult speech not appropriate for their own speech, language, and cognitive abilities Stressful speaking situations for children: competing or hurrying to speak, having too many things to say Stressful life events: moving, divorce of parents, loss of family member, illness, or accident Self awareness: atypically high awareness of own disfluencies Precipitating Factors

Who Is At Risk for Chronic Stuttering? Much greater frequency of disfluencies Who Is At Risk for Chronic Stuttering? Longer duration disfluencies Change in disfluency type Shift away from word/phrase repetition to sound/ syllable repetitions and prolongations and blocks/ tense pauses Evidence of struggle (not easy disfluency) - Selected aspects of the communicative environment - Selected aspects of the child’s overall speech/language development Lack of rhythm in disfluency More “adult-like” patterns that include increased level of awareness, fear and frustration

Recent Evidence from Brain Imaging Persons who stutter show anatomical differences in key speech areas of the brain However, most studies performed on adults who have been stuttering their whole life Are the brains differences the cause of stuttering or the effect of a lifetime of stuttering? New evidence suggests even young children who stutter show brain differences 18

How does we assess stuttering? Referral Case History Careful observation of speech behavior Collect speech samples Measure frequency and type of stuttering Collect information about attitudes toward speaking Plan treatment Prognosis 19

Important for other professionals to recognize warning signs and make referrals to SLPs Warning signs for developmental fluency disorders: Repetition of words or parts of words that involve 3 or more repetitions, prolongation of a sound, feelings of frustration or embarrassment towards communication Warning signs for acquired fluency disorders: “stuttering-like” or “cluttering-like” disfluencies, inability to effectively communicate Referral

How are Fluency Disorders Identified? Determine if the quality and/or quantity of disfluencies significantly differ from normal Quantity: two common metrics Average # of disfluencies per 100 words Average # of disfluencies per 100 syllables Quality: Normal: interjection and revisions predominate Disordered: repetitions, prolongations, and blocks predominate

Diagnosis More likely to be diagnosed if the following ??? are observed during assessment: At least 10 total disfluencies per 100 words At least 3 total “stuttering-like” disfluencies per 100 words Physical escape behaviors Verbal avoidance behaviors Also need to determine the severity, prognosis, and treatment recommendations

Recovery from Stuttering Difference between prevalence and incidence rates indicate that the majority of persons (perhaps 80%) who exhibit fluency disorders do recover Raises question concerning need for treatment (i.e., to treat or to wait and see)

Early intervention vs. “wait and see” approach Three reasons why treatment is necessary: Children who recover from stuttering often do experience stuttering for a relatively long time No way to know whether children will eventually recover or not Relatively high rate of co-occurring speech and language problems that exist beyond fluency disorder

A Critical Period for Recovery from Stuttering If children do not recover by age 6 or 7, they are likely to develop chronic stuttering Older children rarely achieve normal fluency, and the negative consequences increase over time Negative social and emotional consequences can be minimized with appropriate early intervention

Treatment Approaches Speech therapy medication

Speech therapy Helping children learn to speak more fluently Changing the timing and tension of speech production Helping parents learn to facilitate children’s fluency in everyday speaking situations Parents can change their own speech and manage children’s speaking situations to help them speak fluently

Medication Theoretical Rationale Studies have shown that the use of medication is effective in reducing stuttering due to dopamine blocking medications Reduction of stuttering results in decreased anxiety which lessens the amount of medication needed

Medications/Drug Treatments Risperidone Olanzapine Pagoclone Alprazolam Citalopram Haloperidol Appear to make some PWS more fluent, but most eventually discontinue because of unacceptable side effects such as drowsiness and nausea

Recommend? We do NOT recommend this approach Lack of research on effectiveness Long-term side effects are unknown Medications are costly Generalization is unknown

Reference Stuttering. American Speech-Language-Hearing Association. http://www.asha.org/public/speech/disorders/stuttering.htm. Accessed July 21, 2014. Childhood-onset fluency disorder (stuttering). In: Diagnostic and Statistical Manual of Mental Disorders DSM-5. 5th ed. Arlington, Va.: American Psychiatric Association; 2013. http://www.psychiatryonline.com. Accessed July 21, 2014 The facts. Stuttering Foundation of America. http://www.stutteringhelp.org/Default.aspx?tabid=17. Accessed July 21, 2014