CHAPTER 10 Assessment and Management for Atypical Fluency

CHAPTER 10 Assessment and Management for Atypical Fluency Disorders Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 1

Cluttering Neurogenic stuttering Psychogenic stuttering Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 2

Definitions of cluttering Revised (DSM-III-R) (1987): The essential feature of cluttering is a disturbance of fluency involving an abnormally rapid rate and erratic rhythm of speech that impedes intelligibility. Faulty phrasing patterns are usually present so that there are bursts of speech consisting of groups of words that are not related to the grammatical structure of the sentence. The affected person is usually unaware of any communication impairment. (pp. 85– 86) Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 3

Definitions of cluttering (continued) St. Louis and Rustin (1992) . . . a speech-language disorder, characterized by abnormal fluency that is not stuttering and a speech rate that is rapid, irregular, or both. (p. 299) Daly’s (1992) . . . a disorder of speech and language processing resulting in rapid, disrhythmic, sporadic, unorganized, and frequently unintelligible speech. Accelerated speech is not always present, but an impairment in formulating language almost always is. (p. 107) (Figure 10 -1, Linguistic disfluency model) Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 4

Cluttering as a cognitive-linguistic problem: De-emphasizing rapid speech rate (Daly and Burnett, 1999) (Figure 10 -1) A person who clutters will exhibit at least one disturbance in each of the 5 dimensions: • • • Cognitive—total lack of awareness of cluttering, poor attention span, poor auditory memory. Language—expressive & receptive difficulties, poor readers, little interest in music or literature. Pragmatics—poor turn-taking, introducing, maintaining, and ending a conversation. Speech—irregular rate, accelerations, sporadic bursts, variable intensity, poor rhythm. Motor—clumsy and uncoordinated, impulsive motor movements. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 5

Characteristics of cluttering The most basic features • Excessive rate & uneven rate (missing sounds and syllables) • Inattention to grammatical details • Delayed speech & language development • Poor reading comprehension • Immature/inappropriate responses • Unorganized writing Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 6

An example of cluttered writing F. Myers and P. Kissagizlis, ISAD Conference, 2007 Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 7

Cluttering: A writing sample Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 8

Myers & Kissagizlis, 2007 Example of “unguarded typing” After years of feeling insecure, differnt, isolated and excluded, I know Kknow the comndition I have, which is clutteroimng, although it is not cured and nebver can be as fra as I am aware, at lwast I am aware of the conditini aadn people wil learn from tihs, and poepke who sufer as I do wil be able t undrestand what they ahve, the amin thinsg is, peiopokle worlkd wide awil be able to reecognise the condition and maybe the ptofessionals can impement a suitable treainhg/teacjhing athen evebntaualy a treatment regime. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 9

Other features • • Fluency breaks are not SLDs—unfinished words, revisions, repetitions of words and phrases Few accessory or coping behaviors Unaware of their unintelligible speech Unaware of listener reaction Monitoring results in better speech May be stuttering-cluttering (20– 30%) Pure cluttering occurs ~ 5% Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 10

Distinguishing cluttering & stuttering n n n Stutterers know what they want to say but are interfered in their attempt to produce various words, whereas clutterers do not necessarily know all of what they want to say, or how, but say it anyway. (St. Louis et al. , 2007) Fluency breaks are not those typically produced by individuals who stutter (i. e. , part-word repetitions, monosyllabic word repetition, and dysrhythmic phonations), but rather take the form of interjections, unfinished words, revisions, repetitions. (St. Louis et al. , 2007) A clutterer is not likely to associate fear or avoidance with specific sounds or words. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 11

A rate-regulatory problem: Acoustic and spectrographic analysis • An acoustic analysis of cluttered speech by Martin, Kroll, O’Keefe, and Painter (1983) indicated: • a lack of distinct vowel formant structure, release of energy for stop bursts, and aperiodic fricative energy. • Substitutions and distortions of phonemes such as /s/, /r/, or /l/ have also been noted. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 12

A rate-regulatory problem: Acoustic and spectrographic analysis (continued) • Baker, Raphael, Myers, and St. Louis’s (2000) spectrographic analysis found: • although listeners perceived C’s speech rate as extremely fast, the number of syllables/s fell within the normal range. • Rate perceived as rapid due to the omission of many sounds and syllables. • Clutterers produce conversational speech at a rate faster than their systems can handle. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 13

Accompanying characteristics Clutterers often reported to possess • • ADHD—distractibility, inattention to detail, lack of follow through. Learning disabilities—poor handwriting and musical abilities. Apraxia—more pronounced during production of longer, more complex words. Some reports of Tourette’s Syndrome, autism, Asperger, pervasive developmental delay, OCD. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 14

St. Louis, Myers, Faragasso, Townsend, & Gallaher (2004) n 48 listeners rated two young male speakers who cluttered across 5 attributes: • Naturalness, articulation, language, disfluency, and rate. n Listeners used 9 -point equal-appearing interval scales. • Score of 1 represented “highly natural” or “excellent” • Score of 9 represented “highly unnatural” or “very poor” n n Listeners found attributes of rate and naturalness to be least acceptable, followed by speaker’s articulation. Most acceptable were fluency and language. Results supported concept that a distinguishable characteristic of cluttered speech is the rapid and irregular rate of speech. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 15

Assessment • Cluttering Assessment Program (freeware on SHP) • Computer-based tool with 2 tracks for indicating severity: n n 1 st track—computation of % of talking time cluttered or noncluttered from individual or cumulative samples 2 nd track—visual analog scaling procedure, listener rates speaker on 9 dimensions: speaking rate, rate regularity, disfluency, syllable production integrity, overall articulation Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 16

Assessment (continued) • • Computer based tool with 2 tracks for indicating severity (Continued): accuracy, naturalness, pragmatic language appropriateness, language coherence, and thought organization. Self-Awareness of Speech Index (Table 10 -1) • 14 -item measure provided criterion-referenced indication of a speaker’s lack of awareness of their own speech characteristics. • Includes: oral motor problems /general coordination, handwriting, central auditory problems, reading comprehension, spelling, and math skills Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 17

Assessment & progress n St. Louis et al. , (2007) Table 10 -2, Clinical Signs of Diagnostic Significance n Daly (2006) Figure 10 -3, Predictive Cluttering Inventory (PCI) n Daly (2006) Figure 10 -4, Cluttering Treatment Profile Analysis Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 18

Assessment & progress (continued) Predictive Cluttering Inventory (PCI) (Daly, 2006) n 33 -item checklist of 4 speaker characteristics • Pragmatics, 10 statements • Speech-Motor, 10 items • Language-Cognition, 8 items • Motor Coordination-Writing Problems, 5 items Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 19

Assessment & progress (continued) n n Listeners rate frequency of occurrence: ALWAYS (6 points), NEVER (0 points) Scores of >120 Pure Clutterer; 80 -120 Clutterer- Stutterer n Most frequent characteristics of cluttering: omits, transposition of sounds and syllables; and lack of effective, sufficient self-monitoring skills. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 20

Possible problems during • Speaker’s Lack of awareness of • Rate • Inability to effectively communicate • Denial/resistance • Other personality characteristics • Compulsivity, poor concentration, pragmatic issues, intolerance of interruptions Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 21

Other treatment issues • In extreme cases • • • Immature responses, short temper, history of emotional problems Appears defensive/antagonistic Unable to tolerate slower rate • However, when able to monitor • • Dramatically improve fluency and intelligibility Make appropriate alterations even without instruction Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 22

Other treatment issues (continued) • With multidimensional characteristics of speakers the clinician is likely to consult with psychologists, neurologists • Regardless of selected technique, all authors stress daily practice and support of family, friends, and support groups. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 23

Cluttering 3 basic treatment principles • Frequent repetition of therapy goals and rationale will be necessary. • Clinician should provide immediate and direct feedback. • Parents and significant others should play a major part in providing feedback, correction, and reinforcement. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 24

Treatment recommendations (Meyers, 1992; Louis and Myers, 1995) The underlying goal of treatment is to help the speaker to enhance the synchrony of language formulation and the rate of speech production. Primary emphasis is on enhancing the coordination of the linguistic and articulatory levels in order to prevent “derailment” of the speech sequence at either of these levels. Another key element is increased awareness by the speaker of the excessive rate or “haste” associated with both linguistic organization and motoric/articulatory production. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 25

Treatment techniques • Several stuttering modification/fluency-shaping techniques can be used to increase awareness and aid rate and fluency changes • Many activities (particularly when written or verbalized) can server a variety of functions across categories (see pp. 508– 510 in text) Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 26

Acquired stuttering Neurogenic Stuttering Psychogenic Stuttering Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 27

Acquired stuttering (continued) n Occurs for the first time in adults following years of normally fluent speech (mean onset in 40 s) n The possibility of relapse (after successful Tx), or overt characteristics of speakers who managed it in a covert “interiorized” manner n Likely to have rapid onset n Can be difficult to diagnose, especially in distinguishing neurogenic from psychogenic Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 28

Characteristics of neurogenic stuttering Characteristics that MAY Occur for Speakers with Neurogenic Stuttering • • • No reported history of previous fluency problems. Evidence of sudden progressive degrading speaker’s CNS. Fluency-enhancing techniques do not result in significantly improved fluency. Fluency does not improve during automatic speech tasks. There is a tendency for stuttering to occur on medial and final syllables of words. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 29

Characteristics of neurogenic stuttering (continued) n Compared to developmental stutterers there is less of tendency to demonstrate: • • • improved fluency w/repeated readings of a passage. variability in fluency across speech tasks or speaking situations. struggle behavior, emotional reactions, and secondary behaviors, particularly at the onset of the problem. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 30

Characteristics of neurogenic stuttering (continued) • Higher occurrence in males • May be suddenly or unambiguously associated w/head trauma, stroke, cryosurgery, drug usage, or anoxia. • The association with neurological damage is less obvious with slowly degraded fluency • Other terms: late or adult onset, cortical stuttering, organic stuttering, SAAND (Stuttering Associated with Acquired Neurological Disorders) Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 31

Caution during assessment • • Although individuals with neurogenic stuttering have some unique characteristics, Van Borsal (1997) cautions that clinical symptoms alone are not adequate to distinguish from developmental stuttering. De Nil et al. (2007) • Generalized criteria don’t provide specificity for individual speakers who’ve acquired fluency problems from particular insults or disease processes • Exceptions to identifying characteristics used in past • Medial & Final vs. Initial • Lack of secondary behaviors and anxiety/emotion Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 32

Neurogenic stuttering: Assessment Two Unique Characteristics • Relative ineffectiveness of fluency-enhancing techniques that tend to immediately eliminate stuttering for most people w/developmental stuttering (e. g. , choral speaking, whispering, singing) • More likely than those w/developmental stuttering to produce disfluencies during automatic speech tasks such as counting, naming days of week, etc. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 33

Neurogenic stuttering: Assessment (continued) • • Assessment needs to be thorough & individualized Table 10 -3, De Nil et al. (2007), Assessment Battery for Acquired Stuttering in Adults (ABASA) • • Case history General communication functions Speech fluency assessment Speaker self-assessment of attitudes Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 34

Treatment procedures: Neurogenic n Not all individuals with neurogenic forms of disfluenices will require treatment n Stroke patients often recover a period of weeks of months n Closed head trauma resulting from seizures often improve once seizures subside n Parkinson’s patients are more responsive to treatment than stroke patients n Fluency-shaping and stuttering-modification techniques typically used Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 35

Characteristics of psychogenic stuttering • • • The rarest form of fluency problem; most people with developmental stuttering do not have emotional problems Possible for rapid improvement with treatment (counseling and traditional fluency therapy) May show bizarre struggle or anxiety behavior Stuttering may be situation specific Unusual grammar, bizarre speech & movements Psychopathology not always present Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 36

Psychogenic stuttering • • Conversion reaction related to anxiety and depression Case history information especially important • History of emotional or neurological problems? • • Appear to be “holding on” to stuttering (miming) Rapid reduction in stuttering following diagnosis or treatment Rapid improvement after disclosing emotionally sensitive information Worsening of behavior with less difficult tasks Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 37

Treatment options • • • Traditional treatment, possibly with a psychologist or counselor Rule out organic causation Changing the speaker’s belief system (Baumgartner & Duffy, 1997); changing the way they think about the problem is more important than producing fluent speech Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 38

Treatment n Baumgartner says that goals should be “open-ended” because there are so many different behaviors exhibited n Focus on reducing struggle behavior on days that you are not seeing improvement n Don’t rush the speaker to do certain tasks. n As treatment continues show the speaker how to expand his/her fluency. n Baumgartner and Duffy (1997) reported that more than 50% of patients improved to a normal range of fluency after 1– 2 sessions Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 39

Distinguishing between neurogenic and psychogenic stuttering • Many overlapping features of neurogenic and psychogenic stuttering • Conduct a “psychologic interview, ” and look at communicative difficulties in the speaker’s present or past situations • Look for signs of CNS impairment • Remember, there are more reported cases of neurogenic stuttering than psychogenic stuttering. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 40

The possibility of malingering Two types: • Pure—intentional faking all symptoms of a physical or mental disorder • Partial—exaggerating existing symptoms • Both of these are used to achieve a form of gain or advantage (e. g. , defense in robbery trial) Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 41

Determining malingering (See accounts by Bloodstein, 1988; Seery, 2005; Shirkey, 1987) n n To assess this, many speaking samples were collected in different situations, a full case history was evaluated, and indirect tests of malingering stuttering were performed Instances of unusual consistency (vs. typical variability) of stuttering. Copyright 2010 Delmar, a part of Cengage Learning. ALL RIGHTS RESERVED. 42