Speech Disorders #3

CAS is a neurological childhood speech sound disorder in with the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits (e.g. abnormal reflexes, abnormal tone)

The core impairment is in planning and/or programming spatio-temporal parameters of movement sequences, resulting in errors in speech sound production and prosody (sing-song intonations that go with speech)

Less

The complex of behavioral features reportedly associated with cas places a child at increased risk for early and persistent problems in speech, expressive language, and the phonological foundations for literacy, and the possible need for augmentative and alternative communication.

• imitating, 
• reading

• Speech disorder
• change over time

• Dynamic,
• changes over time
• neural maturation or as a result of treatment

• a speech sound disorder
• occur and overlap

The most appropriate label to describe that child changes too.

Children with speech sound disorder

Problem with movement sequences related to sounds. Focus is on the movement

• phonological, semantic, syntactic
• their movement difficulties ONLY

CAS, Dysarthria and phonological all overlap and exist in speech sound disorders

NO they can overlap but they are not the same thing.

It is a motor speech disorder. The muscles of the mouth, face, and respiratory system may become weak, move slowly, or not move easily.

Slurred speech

nervous system (neurological) disorders such as stroke, brain injury, brain tumors, and other conditions that cause facial paralysis or tongue or throat muscle weakness. Can be caused by medications

• 1. Difficulty with achieing initial articulatory configuration
• 2. Difficulty moving from one articulatory configuration to another
• 3. Groping and or trial and error behavior (trying to move in the way you want)
• 4. Presence of vowel distortions (neutral)
• 5. Limited consonant and vowel repertoire
• 6. Use of simple syllable shapes
• 7.Frequent omissions of sounds
• 8. Increased errors with increased word length and phonetic complexity
• 9. Difficulty completing a movement gesture for a phoneme easily produced in a simple context, but not in a longer one.
• 10. Connected speech poorer than isolated word production
• 11. Altered suprasegmentals (lexical and sentential stress as well as overall prosodic contours) what conveys question, exlamation or period.
• 12. Altered timing between sounds and syllables
• 13. inconsistent error patterns.

• 1. Quiet baby: did not play with sounds or babble much.
• 2. When babbling occured, it was undifferentiated (included few or no consonate sound)
• 3. little attempt to imitate sounds or words
• 4. resists attempts of adults/others to get him to imitate sounds/words
• 5. Limited vocabulary for age level
• 6. Poor intelligibility
• 7. Attempts to communicate through gestures, vowel sounds or other means
• 8. Demonstrates frustration at not being understood but seems to understand at an age-expected level

• Voicing errors
• Difficulties with sound sequencing (Metathetic errors, transposition of sounds/syllables and difficulty with a particular sequence of sounds even when the individual sounds are correct in isolation or CV combinations)
• Resources may be allocated to planning articulatory movement and thus not available for planning appropriate prosody. 
• Children have been taught to speak 'syllable by syllable' to say multisyllabic utterances correctly
• Errors increase with increasing length of work or utterance -Easier in one word than conversation
• Supported repetition (drill work) elicits better articulatory performance than the spontaneous production
• Errors are inconsistent across trials
• Articulatory accuracy improves when rate is decreased.

• Difficulty achieving and maintaining articulatory configurations
• Presence of vowel distortions
• Altered suprasegmentals
• Inconsistent error patterns

• Limited consonant and vowel repertoire
• Use of simple syllable shapes
• Frequent omission of sounds
• prosodic errors

• Difficulty moving from one articulatory configuration to another
• Groping and/or trial and error behavior
• Presence of vowel distortions
• Prosodic errors

Yes

• Structural Functional Evaluation
• Check for strength (jaw, lips, tongue) to rule out or identify possible dysarthria
• Velar elevation (timing related issues may be CAS, strength related issues may be dysarthria)

feeding and swallowing but not CAS

• Blow
• Pucker
• Smack Lips
• Cough 
• Sequential imitative movement

• Vowels (collect in phonetic inventory, also elicit variety of vowels)
• Elicit CVVCCVC productions (same C and V and then alternating differeent C1V1C2V2) etc. ahrd time with configuration and movement
• Monosyllabic, bisyllabic, polysyllabic
• Phrases
• Vary temporal aspects of presentations for more specific information (slow it down and pull it down)

• Focus on treatment of movements (not the sound)
• Facilitate movement so that it can be completed with less effort
• Gradual prompting (fading) (work on movements: big-little, tight-loose- fast-slow)
• Initial configuration transition to second configuration (b and oy --> b-oy)

A set of strategies associated with practice and experiences leading to relatively permanent changes in the capacity for movement

Instructions and modeling state why we are practicing

Repetitions help support the neural and behavioral changes necessary for improvement

Speech

MASS ( 50 trials in one sitting is better than 10 trials spread out 5 times a day)

a reduced stimulus set (5-6 configurations at a time)

Specific but back off over time.

• Articulatory
• Tactile/gestural
• Prososdy
• Augmentative models

• Parent knowledge of strategies and cues used is important and the more you do at home the better the outcome
• When enrolled in treatment evaluate if this treatment is necessary with your SLP and consider multimodal communication
• We expect, based on expert opinion that children with CAS will be effective communicators and even up to 75% intelligible (they may have subtle speech differences)

The effortless flow of speech

a disruption or breakdown in the flow of speech

stuttering and cluttering

a type of disfluency disorder that is characterized by a very rapid rate of speech and uneven rate. Many sounds are omitted. Cluttering often emerges in school age children. A person who clutter's is Unaware of his/ her speech patterns.

short burst of stuttering in children followed by periods of relative fluency.

• stop
• persists

Stuttering that will continue to occur throughout an individuals life.

Stuttering/stammering is a communication disorder in which the flow of speech is broken by repetitions (li-li-like this), Prolongations (lllllllike this) and or abnormal blocks of airflow and sound (no airflow- can be audible or visual)

unusual facial and body movements associated with the effort to speak

lots of different ways- lots of variability.

Stutter like disfluency = stuttering

two of the SFA books we are reading use the term stutterer in the tittle. These books are written by a person who stutters. Non-stuttering individuals should use person first language

• Non-developmental stuttering (less common)
• Developmental stuttering

Neurogenic stuttering: results from neurogenic conditions (e.g., brian injury, drug interaction)

Psychogenic stuttering: an extremely rare condition referring to people who have a diagnosed psychopathology (personality disorder etc.) and then later begin to stutter.

developmental or chronic

All languages of the world

• 100 
• 1%

2-5 years of age

• 4x
• males
• females

• 1. Repetitions: at phoneme, syllable, word, or phrase level
• 2. Prolongations: a sound is prolonged longer than 1 second
• 3. Blocks: airflow is blocked by articulators

• normal non- fluencies
• 10%

• Any behaviors that are not primary or core stuttering. 
• Secondary behaviors are learning in an attempt to escape the stuttering movement and may include:
• bodily movements (facial grimace, head movements, eye twitch, other bodily movements) or word avoidance, sentence abandonment, circumlocution, and other behaviors.

idiosyncratic, uniques in each individual, so these secondary behaviors can vary tremendously.

to escape the primary behaviors.

• Stuttering occurs when speaker expects to stutter, dreads it, becomes tense in anticipation and tried to avoid it. 
• Diagnosogenic theory.

• Stuttering beings NOT in the child's mouth but in the listener's (mothers) ear.
• Not true, has been disproven and you can not induce stuttering.

• Stuttering occurs when the flow of speech is interrupted abnormally by repetitions or prolongations of a sound, syllable or articulatory posture or by avoidance and struggle reactions
• these produce interruptions and breaks in the forward flow of speepch.

• Stuttering is an anticipatory-struggle reaction. It represents an exacerbation of the tensions and fragmentations that are common occurrences in the speech of normally developing children.
• Stuttering develops readily in circumstances in which speech pressures are unussually heavy, the child's vulnerability to them is unusually high or communicative difficulties are unusually frequent, severe or chronic

• Johnson emphasized the overlap between children beginning to stutter and children who were normally nonfluent
• Based on the idea that stuttering results from its (mis-) diagnosis
• Stuttering begins not in the child's mouth, but in the listenter's/mother's ear.
• Johnson was wrong this theory has been proven to be inaccurate.
• Monster study

more at risk for stuttering to develop

they are even more vulnerable.

tension and fragmentation which can lead to anticipatory struggle and stuttering

Communicative failure and anticipatory struggle.

Capacities and Demands

• 1. The child's capacity for fluency does not equal environmental demands for it.
• 2. Reduced capacity may be caused by "organic predisposition" for stuttering
• 3. Decreasing the linguistic demands placed upon the child becomes a focus of therapy.

Starkweather

• Genetics (60% of those who stutter have a family history of stuttering)
• Differences in child development (Children with speech-language or developmental delays are more likely to stutter)
• Neurophysiology (there is evidence of "hard wiring differences" in how people who stutter process speech and language)
• Family dynamics (high expectations and fast-paced lifestyles can contribute to or aggravate stuttering)

Although the etiology of stuttering is not fully understood, there is strong evidence to suggest that it emerges from a combination of constitutional and environmental factors

Yes, most non stuttering individuals demonstrate a little bit (<10% of the time) of other dysfluencies or normal non fluencies.

Normal nonfluencies are regular bumps heard in typical speakers' speech.

• Characteristics are:
• easy, effortless, rhythmic, infrequent
• word an phrase repetitions
• revisions, interjections
• usually only one or maybe two reiterations (difference is in frequency)
• Frequently related to revision or formulation of message.

• 1. Part word repetition
• 2. single-syllable word repetition
• 3. multisyllabic word repetition
• 4. Dis-rhythmic phonation (prolongaion)
• 5. Tense pause

• 1. Phrase repetition
• 2. interjection
• 3. revision-incomplete phrase

• Relative to developmental stage
• ex: frustrated, nervous, scared, upset, embarrassed, guilt, shame, denial. 
• AFFECTIVE

• Related more to your beliefs about stuttering and stutters. 
• ex: that stuttering is bad, wrong, nasty, etc. that stutterers are stupid, unworthy
• COGNITIVE

• Sheehan
• the core features are what you see (repetitions, prolongations, blockages.)
• The secondary features are also what you see above the surface ( escape and avoidance)
• But the attitudes and feelings are below the water (fear, guilt, denial, shame)

• DO NOT CAUSE
• Response
• aggravate stuttering

Emotional disorder

• what you can see (above the water)
• What you cannot see (below the water)

Emotional and behavioral (avoidance)

• ONLY BEHVIORAL
• disfluency, fluency failure, stuttering.

ONLY EMOTIONAL

• 32-80% recovery, but problems with methodology in these studies
• Girls recover faster and more frequently then boys

Frequency.

Prolongations

• 74
• 26

• Time post onset (TPO) is a factor: how long since it started
• 6 months or < TPO = high chance of spontaneous ecovery
• 18 months or > TPO = high risk of chronic stuttering. Not all children recover if we ignore it.

in children who are dysfluent past age 6

• Is the child stuttering? If so , what levelof severity do we see?
• Have client's disfluencies and response to disfluencies changed?

Describe surface features of stuttering and describe the internal response and resulting behaviors of stuttering.

• We map surface features of stuttering using a variety of behavioral measures that involve detailed observation and analysis.
• Detailed speech sample
• Dsifluency count (% of stuttered syllables)- number of repetitions, prolongations and blocks. Also number an type of secondary behavior, not a check list, need as much detail as possible. 
• We are interested in: Frequency, tension, duration (longest stuttered moment) secondary behaviors.

the investigation and exploration of speech behaviors that someone has identified as problematic.

a rich clinical description of stuttering

• Molecular Analysis
• of 3 speech samples (250-300) words each
• Conversation, reading, monologue
• You can apply stuttering severity instrument or other scoring framework to this once transcribed.
• Transcribe language
• transcribe speech (because of higher occurrence of phonological disorder)
• Code stuttering in sample

• Calculate:
• *words per second (words/sec)
• Syllables per minute
• MOST IMPORTANT IS PERCENTAGE OF STUTTERED SYLLABLES

severity.

• Not yes or no
• Describe how your son reacts to moments of difficulty with speech/stuttering
• does the child stop talking because it is too hard?
• Other evidence of negative awareness.
• School age children we may also complete an interview and possibley a self rating scale
• For young childen, we gather this information through parent interview that is not infront of child

• 3-4
• 5

• The client to assess him-/herself. 
• great for adults, teens and school age.

• what their overall speech/stuttering is like. Relate to quality of life
• What their speech/stuttering is like right now/time of assessment

it is nice to bring this information into a report using the clients own words.

For school age, teens, and adults, interviews about stuttering are also recommended to tap into internal response to stuttering.

• Fluency Shaping
• Stuttering Modification

Based on the idea that a PWS can become near fluent if they constantly apply their fluency shaping strategies. (goal is fluent speech and they can become fluent if they use the strategies)

Based on the idea that a PWS can mange his/her stutter by facing the stuttering and learning to change and take control over his/her stuttering. (goal is to face stuttering and you will get through life by facing fears. )

• Fluency is established through explicit practice of fluency shaping strategies, including-
• easy onset of voice: adults or children. putting in air to reduce hard adduction, typically h in front of a vowel.
• Breathy speech: more pauses, more air, whispering, spread it out.
• Light articulatory contacts: like a breathy contact. Less contact force.

• SM teaches the PWS to modify his/her moments of stuttering, using stategies inclduing-
• Pseudo stuttering: stutter on purpose to demonstrate control
• Cancelations: by replacing it with a fluent statement
• Pull-outs: Pull out of stuttered moment and finish the statement
• Preparatory sets: Practicing phrases that you may us

SM reduces the fear and negative emotions that the PWS experiences and eliminating the avoidance behaviors associated with this fear.

• Hypnotherapy: a psychologically based approach to the treatment of stuttering. NO EFFICACY for this type of treatment
• Drug Therapy: Use of anti-anxiety medications to reduce moments of stuttering. Does not cure or treat stuttering- rather treats anxiety associated with stuttering.
• Electronic Devices (Easy speak and delayed auditory feedback devices): closely resemble hearing aids that provide an auditory distraction to help alter the individual's overall speaking behavior. A treatment approach not a cure ($4000)

NO

• There are no instant miracle cures for stuttering
• However, a specialist in stuttering can help not only children but also teens, young adults, and even older adults make significant progress toward fluency and STUTTERING LIGHTLY.

• Finish what they want to say
• Say: take a breath, slow down.
• Look away.

• 1: Make a habit of always talking slowly and deliberately whether you stutter or not
• 2:When you start to talk, do it easily, gently and smoothly without forcing and prolong the first sounds of words you fear
• 3: Stutter openly and do not try to hide the fact that you are a stutterer
• 4: Identify and eliminate any unusual gestures, facial contortions, or body movements which possibly you may exhibit when stuttering or try to avoid difficulty.
• 5: Do your best to stop all avoidance, postponement or substitution habits. 
• 6: Maintain eye contact with the person to whom you talk
• 7: Analyze and identify what your speech muscles are doing improperly when you stutter
• 8: Take advantage of block correction procedures designed to modify or eliminate your abnormal speech muscle stuttering behavior
• 9: Always keep moving forward as you speak
• 10: Try to talk with inflection and melody in a firm voice
• 11: Pay attention to the fluent speech you have
• 12: Try to talk as much as you can