I’m watching a video of one of my students. I’m
typing what he says and marking each stuttered word, listening to some of his sentences over and
over again to accurately label blocks,
prolongations, repetitions and secondary behaviors. I can think about a
child’s speech more sensitively this way than if I try to take a frequency
count in real time.
It takes several hours to transcribe and
score a speech sample this way. I’ve been doing it for more than 20 years. In
1992, I learned a detailed protocol called Systematic Dysfluency Analysis (SDA)
[1].
It introduced me to careful listening.
Eventually, I had to admit that SDA took too much time. In 2010, I bought the
Test Of
Childhood Stuttering (TOCS)[2]
which provided a simpler method. I knew that most speech language pathologists
(SLPs) used the Stuttering Severity Instrument (SSI).[3] However, as a specialist, I felt obliged to
offer an alternative. The
Stuttering Foundation has a continuing
education video called Scoring Disfluencies,[4]
an excellent resource for anyone interested.
In this blog post, I'd
like to reflect on what speech analysis means. For starters, certain types of
disfluency are considered stuttering and others are not. The distinction is
especially relevant when considering whether or not a young child might be at
risk for developing a chronic stuttering problem. Disfluency types can
differentiate between stuttering and cluttering. And, sometimes, I see children
show progress by gradually changing the type of disfluency they produce, even
if frequency stays the same. The American Speech Language Hearing Association (ASHA)
website has a thorough review of this information for SLPs in Clinical
Topics: Childhood Fluency Disorders. There is quite a lot of information for the
public at the ASHA site as well.[5]
Any presence of physical tension is usually
labeled stuttering. One form of tension
is a laryngeal block. This is when the vocal cords (located in the larynx) stop
vibrating. Speech seems to be stuck in the throat. This may
take a fraction of a second or up to several seconds. Tension may also appear in the face and/or
neck. It can spread through the torso. A change in timing, a
prolongation, is another form of stuttering. It is a sound that lasts too long
and fails to transition quickly into the
sound that follows. These two types of stuttering are called “disrupted phonation.” [6],
[7]
Parents may not realize disrupted phonation
in their child's speech could be stuttering. It's the repetitions that usually
trigger concern. Friends, family and even pediatricians say ‘ wait and see’,
maybe the toddler will pass through a common phase called developmental
disfluency. Most young children do “outgrow” this. But the mystery remains;
which children will develop normal speech and which children will stutter?
Research conducted in the 1990's identified
disrupted phonation (blocks and prolongations) as associated with chronic
stuttering. Disrupted phonation, whether it has a sudden or gradual onset is
probably not normal. It turns out that some kinds of repetition are probably not
normal either. Atypical repetitions
along with disrupted phonation are called Stuttering
Like Dysfluency (SLD). A careful
speech analysis will determine precisely what kinds of disfluency is occurring.
A special calculation called the "weighted stuttering like disfluency" has been found to discriminate between young children who do and do not stutter. It
combines repetitions and disrupted phonation in a mathematical formula .[8]
In fact, a weighted SLD measure of 4 identified 97% of children (35/36 children
ages 3 & 4 years) in one study.[9]
It is important for parents to know that blocks and prolongations could be
warning signs of chronic stuttering.
A careful speech analysis will count three
types of repetition. Two types are associated
with stuttering in young children: repeating parts of words (I w-w-w-want; I
want pop-pop-popcorn.), and repeating single-syllable whole words (I
want-want-want popcorn.)[10]
In addition, the number of iterations is relevant. This is because the presence
of a single repetition (I w-want) versus multiple iterations (I w-w-w-want) also
distinguish between children who stutter (CWS) and children who do not stutter.[11]
These guidelines have been revered for decades due to extensive research support.
For some children, stuttering apparently worsens
with time.[12]
One research team proposed that these children “may be encouraged, by a more
positive listener reaction, to use increased physical tension to stabilize (or
make less obvious) part word repetitions."[13]
This didn't make sense to me. Rather, my intuition is that the older children's
speech contain more SLDs because it always
did. By this I mean, children arriving at a clinic for evaluation at age four
would be those who always had more disrupted phonation. But then I read The
Genius of Dean Williams. [14]
In chapter 9, he recalls the following: "One second grade boy reported
that when he was in kindergarten and first grade he had repeated sounds a great
deal. People called it 'stuttering.' Now, he tensed and 'pushed' to get the
words out so he wouldn't 'repeat,' or 'stutter,' as he understood the meaning
of the word." I was in awe that Dr. Williams could elicit such insights from
a youngster.
Recording single-syllable whole word
repetitions as stuttering is not universally accepted. "There is
evidence...that children who recovered from stuttering showed a greater
proportion of WWR than those who did not [and] ...Riley (1994) as creator of
the SSI-3 asserts that WWRs should not be counted as moments of stuttering, as
long as they are not disrhythmic."[15]
Why all the fuss over counting single
syllable whole words? Well, we’re talking
about accurately diagnosing children at risk for persistent stuttering
and recommending who should receive treatment. If we dismiss all childhood
disfluency as something children outgrow, parents may not seek appropriate help. Or maybe the opposite. Maybe parents will be unnecessarily concerned.
It turns out that "...as a group, bilingual children produce
higher levels of typical speech disfluency than their monolingual peers." [16]
Repetitions ranged from 3-22% and number of iterations 4-8 in a recent study of
Spanish-English speaking children. It may be that the guidelines for diagnosis
revered for decades actually applies only to monolingual children. Here is a danger of incorrectly labeling children
at risk for stuttering. “…at present, researchers do not have a sufficient understanding of
the disfluent speech of bilingual children who do not stutter. Thus, it is
difficult to determine whether a bilingual child is in fact at risk for
stuttering or if, perhaps, as a group, bilingual children produce higher levels
of typical speech
disfluency than their monolingual peers.”[17]
I began
this blog because I was working with a middle schooler. I didn’t find anything
new in the ASHA journals for this age group. I did come across an article that validated
a common phenomenon. A group of children
who stuttered ages 6 years old to 10 years and 5 months old, stuttered more in
narrative than in conversation.[18]
What’s the difference between having a conversation with someone versus
recalling a story?
A
conversation is a shared experience. Speakers pay attention to one another.
They interpret facial expressions, body language, tone and loudness of voice and
changes in topic. There is time pressure to access language and speech/motor
skills in socially acceptable ways. It matters who’s talking and the speaking situation. Conversation can
be challenging! CWS in this study used shorter
utterances in conversation than in narrative. Any surprise here? I’ve certainly
seen this.
Okay, let's take a look at narrative. The
speaker is completely responsible for all of the information, language,
non-verbal messages, and listener reaction. It’s the speaker's job to keep a
listener’s interest and ensure that he understands the message. Here’s two
reasons a story telling activity would have been more difficult in this particular study. Reason number 1: "...children [need] to hold a series of
sequential intentions in memory while simultaneously planning and executing the
motor movements required...” Reason number 2: “…the utterances the CWS produced during
narration were longer than the utterances they produced during conversation,
thus creating the context for motor system instability…”[19] Narrative is also quite challenging! This
research suggests that narrative may be an efficient tool for gathering a
speech sample.
The results of a speech analysis are combined
with other information to help in the accurate diagnosis and the selection of treatment for CWS. For the older
child, I refer to lessons found in Easy Talker[20],
my own workbook[21],
and the Stuttering Treatment Guide. [22]
I’m also taking another look at the workshop booklet from Dr. Dean Williams’
presentation I attended in 1993.[23] School-Age Stuttering Therapy is another
superb resource.[24] The Stuttering Foundation has many videos about treatment taught by highly respected experts.
This is just a personal reflection. I can only speak from my personal experience. I’ve had 20+ years to form opinions and a
clinician bias. I’m looking forward to retiring soon and hope to contribute to
the field in ways other than studying speech samples. I’m looking forward to
future generations of SLPs bravely taking on the challenge of stuttering
therapy.
Thank you for reading,
Judy
[1] Systematic
Disfluency Analysis Campbell, J. H. & Hill, D.G.
(1987) Systematic Disfluency Analysis, Stuttering Therapy: A Workshop for Specialists,
IL: Northwestern University
[2] R.B. Gillam, K.J.
Logan, N.A. Pearson (2009) Test of Childhood Stuttering Austin TX: pro-ed.
[3] G. D. Riley (2009) Stuttering Severity
Instrument, Austin TX: pro-ed, inc.
[4] Diane Parris, Scoring Disfluencies,
Stuttering Foundation DVD No. 6350. www.stutteringhelp.org
[6] E. Yairi and N. G. Ambrose (2005)
Early Childhood Stuttering: For Clinicians By Clinicians, Austin, TX: pro-ed,
p. 97.
[7] Let’s remember, too, that some
speakers say they stutter when no dysfluency is evident to the listener. This phenomenon is called covert stuttering.
[8] The
weighted SLD is "calculated by multiplying the number of part word
(PW) and single syllable (SS) repetitions (PW + SS) per 100 words spoken by the
mean number of repetition units (RU) and adding the result to two times the
frequency of disrhythmic phonation (DP), thus yielding the following formula:
([PW + SS] x RU) + (2 x DP), as described by Ambrose & Yairi (1999, p.
899). 2002 p. 23." M. W. Pellowski
& E. G. Conture (2002) Characteristics of Speech Disfluency and Stuttering
Behaviors in 3- and 4- Year Old Children, Journal of Speech, Language, and
Hearing Research, vol. 45, 20-34.
[9] Ibid p. 26
[10] E. Yairi and N.G. Ambrose (2005) p. 96.
[11] M. W. Pellowski & E. G.
Conture p. 26. “In general, findings indicated that the percentage of total
disfluencies, percentage of stuttering-like disfluencies, weighted SLD measure,
and mean number of repetition units significantly differed between CWS and
CWNS, whereas the percentage of other disfluencies did not significantly differ
between the two talker groups.”
[12] Ibid. p. 26 “…that increases in time
since stuttering onset were associated with increases in the percentage of
stuttering-like disfluencies for all CWS.”
[13] Ibid, p. 31.
[14]
Stuttering Foundation Publication No. 0425, p. 96.
[15] David Ward (2013) Risk Factors and
stuttering: Evaluating the evidence for clinicians. Journal of Fluency Disorders, 38, p. 138.
[16] C.T. Byrd, L.M. Bedore & D.Ramos (2014)
The Disfluency Speech of Bilingual Spanish-English Children: Considerations for
Differential Diagnosis of Stuttering, Language,
Speech, and Hearing Services in Schools, Dec. 10, p. 10.
[17] Ibid. p. 10
[18] C.T. Byrd, K.J. Logan, R.B. Gillam (2012)
Speech Disfluency in School-Age Children’s Conversational and Narrative
Discourse. Language, Speech, and Hearing
Services in Schools, 43, p. 160.
[19] Ibid. p. 160.
[20] B. Guitar & J. Reville (1997)
Easy Talker: A Fluency Workbook
for School Age Children, Austin, TX: pro-ed pro-ed, 1997
[21] J. Butler (2014) Respecting the
Communication Needs of Children Who Stutter, This has been removed.
[22] The Child and Adolescent Stuttering Treatment and Activity Resource
Guide, Second Edition, Delmar Cengage Learning, 2010
[23] D. Williams (1993) Stuttering
Therapy for Children: Learning to Learn, University of Wisconsin-Milwaukee,
School of Allied Health Professions, Office of Continuing Education
[24] N. Reardon-Reeves & J. S. Yaruss
(2013) School-Age Stuttering Therapy: A Practical Guide. McKinney, TX: Stuttering
Therapy Resources, Inc. www.StutteringTherapyResources.com
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