Claudia Regina Furquim de Andrade Full Professor e

Claudia Regina Furquim de Andrade Full Professor e. mail: clauan@usp. br tel: +55 11 30918406 Division of Speech. Language and Hearing Pathology – Hospital das Clínicas, School of Medicine, University of São Paulo, Brazil

Fabíola Julia Fernanda Ana Paula

• Speech is a complex neural function that involves segmental (linguistic) and suprasegmental (paralinguistic) components, processed by different neural pathways. When integrated and synchronized, these components are critical for maintaining a smooth and continuous flow, which we call fluency. Breaks in this flow represent disfluencies, which are classified as common (hesitations, interjections, revisions, unfinished words and repetition of words, segments or phrases) or stuttering (repetition of sounds or syllables, prolongations, blockages, pauses and intrusions)

Directions Into Velocities of Articulators – DIVA Frank H. Guenther Department of Cognitive and Neural Systems –CNS (Boston University) Harvard-MIT Speech and hearing Biosciences and Technology Program Athinoula A. Martinos Center for Biomedical Imaging (Massachusetts General Hospital)

Developmental Stuttering

• Stuttering is understood as a metabolic hereditary disorder, that presents different characteristics of chronicity and different severity levels; • A possible cause is that it is genetically transmitted: An inability to perform automatic updates of the internal models (relative to the dynamics of the effector motor execution system), having a sensorial consequence of movement repetitions or blocks that prevent the completion of the motor order. This leads to the continuous re-setting of the system. Max, 2007; van Lieshout, Hulstijn e Peters, 2007 – based on Internal models of sensory motor control

Numerous studies have demonstrated the benefit of devices delivering altered auditory feedback as a therapeutic alternative for those who stutter. Background

• Purpose: To perform a systematic review of studies related to the effects of delayed auditory feedback on speech fluency in individuals who stutter

• Research strategy: Concepts of the Cochrane Handbook were followed: formulation of initial question (theme to be reviewed), location and selection of studies (Pub. Med database) and compatibilization among researchers (aiming to minimize possible citation losses)

• Selection criteria: The following were excluded: citations in languages other than English, citations that did not allow access to full text, repeated citations due to the overlap of keywords, studies developed exclusively with fluent individuals, case reports, reviews of the literature, letters to the editor, and texts that were not directly related to theme. Hence, texts that were related to treatment with delayed auditory feedback (DAF) and frequency-altered feedback (FAF) were analyzed.

• Data analysis: Data were analyzed according to research indicators and according to study quality markers. • Results: The results indicated that the use of altered auditory feedback devices for the reduction of stuttering events still do not have robust support for their applicability. Methodological variability does not allow a consistent answer, or a trend about the effectiveness of the device, to be drawn.

• Conclusion: Although the limitations in the studies prevent generalizations about the effectiveness of the device for the reduction of stuttering, these same limitations are important resources for future research planning.

• The literature review on AAF (altered auditory Feedback) indicated the Speech. Easy as the device that has been mostly investigated for its effects. • The Speech. Easy is a device that combines both the effects of DAF (delayed auditory feedback) and FAF (frequency altered feedback), delivering at the same time a delay in the auditory feedback and a modification in frequency. • The fitting of the device is made using a computer program. The delay in the auditory feedback varies from 0 to 220 ms and alterations in frequency varies from -2000 Hz to +2000 Hz. • The Speech. Easy is considered the most modern and complete AAF device availabe in the market.

• Objective: To investigate variations in speech motor skills in adults who stutter and those who do not, using the Speech. Easy® altered auditory feedback device.

• Methods: Twenty adults participated, 10 of whom stuttered (nine males and one female - mean age 30. 9 years) and 10 of whom were fluent controls (nine males and one female - mean age 25. 2 years). The study compared the performance of participants in four tasks: spontaneous speech, alternating diadochokinesis, sequential diadochokinesis and target phrase production, with and without the device. The following variables were analyzed acoustically: (1) diadochokinesis tasks: syllable duration, mean duration between syllables, peak intensity and diadochokinesis rate; (2) target phrase production task: reaction time, voice onset time (VOT) duration, total production duration, fundamental frequency and intensity.

• Results: The spontaneous speech task was the only task to show significant differences in both the intragroup and intergroup comparisons. In this task, the use of Speech. Easy® resulted in significant improvement in speech fluency, as measured by the percentage of stuttered syllables, for the group who stuttered. For the fluent group, the device produced the opposite effect: a significant increase in the frequency of stuttered disfluencies was observed with the device. No significant differences were found in either intragroup or intergroup comparisons relating to the acoustic aspects of the diadochokinesis and target phrase production tasks.

• Conclusion: The results indicated that the use of Speech. Easy® improved the fluency of participants who stutter, without appearing to interfere with speech naturalness.

The effectiveness of a device delivering altered auditory feedback (Speech. Easy®) was compared to behavioral techniques in the treatment of stuttering in a randomized clinical trial. Aims

Two groups of adults who stutter participated: Group 1 consisted of 10 males and 1 female aged 21 -42 years (M =30. 0). Participants in Group 1 were fit with a Speech. Easy® and were not given any additional training (i. e. , supplementary fluency enhancing techniques). Participants used the device daily for six months Group 2 consisted of 6 males and 1 female, aged 20 -50 years (M = 35. 6). Participants in Group 2 received treatment in the form of a 12 -week fluency promotion protocol with techniques based on both fluency shaping and stuttering modification Methods & Procedures

There were no statistically significant differences (p >. 05) between groups in participants’ stuttered syllables following treatment; Both therapeutic protocols achieved approximately 40% reduction in number of stuttered syllables from baseline measures, with no significant relapse after three or six months post-treatment; Conclusions & Implications: The results suggest that the Speech. Easy® device can be a viable option for the treatment of stuttering. Outcomes & Results

The results suggest that the Speech. Easy® device can be a viable option for the treatment of stuttering Conclusions & Implications

Preliminary results (ASHA CONVENTION 2016) • Title: Correlation of auditory a electrophysiological measurements and fluency improvement in adults who stutter. • The purpose of this study was to compare the performance of people who stutter during solo and choral Reading with auditory electrophysiological measurements. Participants who stuttered presented lower stuttering frequency during choral reading. Auditory electrophysiological measurements were not capable of determining accurate prediction of fluency improvement via auditory input.

• Quality of life and Speech. Easy; • Influency of Speech. Easy in differents speech tasks; • Use of Speech. Easy by individuals with Parkinson’s Disease. Future perspectives

Acknowledgements This work was supported by São Paulo Research Foundation (FAPESP grants #2011/10000 -2 and #2014/05265 -5) and by Brazilian National Research Council (CNPq grant #201445/2014 -0).