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Intro to paed stuttering (1) (Impt features of fluency Ax (Holistic…
Intro to paed stuttering (1)
Multifactorial dynamic pathway theory
Cause X well defined
Neurodev disorder--> Neurological, genetic components
Env processes recognised to play impt role in dev stuttering: onset manifests recovery
X single pathological issue, unique interaction b/w variables--> stuttering
For every child, indv levels of vulnerability, demands at lvls, interaction of factors
Genetics
Neurology
Motoric
Lang
Emotional
Emphasis on multilevel events in childhood when stuttering emerges, recovery, persistence occurs
Each child has dynamic pathway into diagnoses of stuttering- recovery (80%) or persistence (20%)
Guitar's 5 levels of stuttering dev
According to ages, stages of dev. of stuttering
Levels of stuttering dev useful in determining most appropriate Tx
5 levels
Normal disfluency
Usually b/w 2;0-6;0
<10/100 disfluent words
Typically one-unit repetitions (sometimes 2)
Eg. Interjections, revisions, (single) word repetition, pauses
Past 3;0- usually show decline in part word repetitions
Continues throughout childhood, adulthood, normal part of dev eg. phrase level repetition, not aware, not concerned .
Factors that may increase occurences
Demands on lang acq-hear basic disfluencies as lang system adjusts
Speech motor skills-speed
Stress-going to school, making friends, new sibling, behaviour issues (ADHD)
Competition, excitement when speaking: attention, getting sth they really want
Being rushed to speak
Borderline stuttering
2;0-3;6 Younger Preschool aged children
10 disfluencies/100 words
More sound, syllable, word repetitions, prolongations, restarts, broken words cf. revisions, incomplete phrases
Minimal secondary behaviours (non-verbal), more covert behaviours eg. blocking silently, talking around
Disfluencies are loose, relaxed
Rare for child to react to their own disfluencies BUT case study: 3;0 puts hand over mouth when she blocks, runs away
Increasing: 2 or more units repeated
Underlying processes
1) constitutional eg. speech, lang dev. - inefficiencies in some lang production processes. 2) Env eg. communication, psychosocial stress (moving house, birth of sibling)
Gnerally not aware, may sometimes show momentary surprise/mild frustration
Beginning stuttering
Older preschool aged children 3;6-6;0
Home env: parents stressed easily, affect child, child might stop talking if parent keeps correcting them. Older siblings cut them off, tease them, competition to be heard
Signs of muscle tension, hurried speech, rapid, irregular, tense repetitions, pitch rise towards end of repetition, prolongation
Fixed articulatory postures when X begin word (blocking)--> muscle tension in oral musculature
Escape behaviours may be present eg. eye blinks, increase in pitch, loudness as disfluency continues
Some awareness of difficulties, possible frustration
Underlying processes
1) Increases in muscle tension
- increased tempo, rate in repetitive stutters, increased articulatory, laryngeal muscle tension as child attempts to control repetitions--> stiffen speech muscles, bracing against involuntary repetitions. Prolongations can become blocks 2) Effects of learning on stuttering:
classical conditioning
: learnt emotional rxn applied to previously neutral situations.
3) Instrumental conditioning
: Increases freq of escape behaviours. X being functional communicator if you have to keep blinking, nodding head
Intermediate stuttering
School-aged children aged 6;0-13;0
Predominant core behaviour is blocking (sound, airflow shut off) : audible, silent
Repetitions, prolongations can be present
Escape behaviours can be used to terminate blocks
Can anticipate blocks--> avoidance behaviours before feared words
May avoid difficult speaking situations
Stronger emotional response before, during, after stuttering: downward spiral of social interaction eg. public speaking in classroom
Underlying processes
1) Classical conditioning
: increased tension when stuttering in more situations.
2) instrumental conditioning
: more complex range of escape behaviours to terminate blocks.
3) Avoidance conditioning
: transform escape behaviours--> word avoidance, revisions, speaking situations completely.
Link goals to relevant examples w/i child's life so more motivating
Advanced stuttering
Occurs in older teens, adults (14;0+)
Longer, tense blocks w associated tremor articulators
Can be suppressed thru avoidance behaviours
Use of avoidance, escape behaviours more complex (can be so quick, habitual that PWS not aware)
Stronger emotions re presence of stutter (dev negative feelings about self as person, communicator). X want to let ppl know you have stutter, X go for interviews, avoid phone calls
Think about env: occupational, daily r/s, competition in speaking
Student let others know he had stutter before presentation: acceptance can go a long way
Underlying processes:
1) Neurological change
- way brain operates in speech has been modified,
2) Avoidance learning
-indv's char patterns of tension eg. escape behaviours, word, situation avoidance becomes automatic, learned, X realise how much it is impacting.
3) Dev. -ve self concept
Features to determine severity of stutter
Stuttering freq, units
how often stuttering occurs when person speaking
% SS
Types of stuttering behaviours
Duration of stuttering moment
How long it lasted for
Increased duration can be risk factor for persistent dev. stuttering. Children tend to recover w fewer repetition units (can be Tx goal)
For block, prolongations count time in seconds
Attitudes, feelings of PWS
Emotional responses to stuttering can start from young age
Children who stutter may start to show
impaired behavioural, emotional, social dev early as 3;0
. Difficulties well established in older children who stutter. Single traumatic event can trigger speech-related anxiety in young child
-ve consequences of stuttering can start shortly after onset during preschool years: can severely afffect social, emotional fning, r/s, QOL, mental health
90% of parents in study affected by child's stuttering. Most freq reported rxns: worry, anxiety, concern, uncertainty about what to do, frustration, upset, self-blame
Dev of social anxiety: relate to -ve conditioning experiences in early childhood w children most likely to suffer form social-evaluative anxiety
Anxiety as one of most freq observed psychological conseq of stuttering
Need to encourage them to not let stutter hold them back, just continue sticking to your values and beliefs in life as before
Tools for Ax: KiddyCAT, temperament, behaviour screening too eg. Langevin, Packman, Onslow (2010)
Impact on QOL
Impt features of fluency Ax
Holistic approach- whole person, fam
Careful obsv, analysis
Client led: client goals are impt
Acceptance
Cultural considerations eg. eye contact, touch, reinforcers, family dynamics, communication styles
Lvl awareness
Functional impact
No. of units, how often
Family history
Severity impt bcos: determining outcomes of Tx, track progress during Tx
Terminology X vs Y
Escape vs. avoidance
Escape: occur after stutter has started, attempt to stop stutter, produce word. Eg. nod head, blink, rocking, closing eyes, frowning, heavy breathing (recollecting himself)
Avoidance: occur before stutter has started, attempt to prevent themselves from starting stutter. Eg. saying extra sound, changing word
Core vs. secondary stuttering behaviours
Core: repetitions, prolongations, blocks
Secondary: escape, avoidance