12/28/14

Counting Stuttered Words

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, a free download at https://sites.google.com/site/judithvbutlermaccc/home/free
[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
Creative Commons License
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.Creative Commons License
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.