Fluency Disorder

A person that presents with a fluency disorder means that they have trouble speaking in a fluid, flowing, or smooth way in order to communicate and be understood effectively. There are two types of Fluency Disorders: Stuttering and Cluttering.

Stuttering

We all have times when we do not speak smoothly. We may add filler words  "uh" or "you know" to what we say, repeat a sound, or say a word more than once.  These disfluencies are normal if they happen every once in a while. However, when it happens frequently it may be  signs of stuttering. Stuttering can change from day to day. You may have times when you are fluent and times when you stutter more (disfluent). Stress or excitement can increase disfluencies.  There are several types of stuttering disfluencies.  

 Types of stuttering disfluencies:

• Blocks. This happens when you have a hard time getting a word out. You may pause for a long time or not be able to make a sound. For example, "I want a ...... cookie."

• Prolongations. You may stretch a sound out for a long time, like cooooooooooookie.

• Repetitions. You may repeat parts of words, like co-co-co-cookie.

Stuttering is more than just the blocks or repetitions in your speech. It can also make you tense your body or struggle to talk.  These are called Secondary Behaviors and may be exhibited in people that stutter.

Types of Secondary Behaviors:

• Covering your mouth or pretending to cough or yawn to cover up stuttering

• Not speaking, even when you want or need to

• Not using certain words that seem to cause stuttering

• Pretending to forget what you wanted to say

• Rearranging words in sentences

• Using “filler” sounds between words to make the rate of speech sound more normal

Stuttering may affect how you talk to others. You may want to hide your stuttering, avoid certain trigger words, refuse to talk in uncomfortable situations, or participate less in social activities. Fear, anxiety, anger, and shame involving speaking are also common.

Cluttering

Like stuttering, cluttering is a fluency disorder, but the two disorders are not the same.  Cluttering is described with the following aspects:

• Characterized by a rapid and/or irregular speaking rate

• Involves excessive breaks (disfluencies) in the normal flow of speech that seem to result from disorganized speech planning

• Talking too fast or in spurts

• Simply being unsure of what one wants to say.

• By contrast, the person who stutters typically knows exactly what he or she wants to say but is temporarily unable to say it.

• In addition, many who clutter are described by themselves or others as "stuttering." Also, and equally confusing, cluttering often occurs along with stuttering.

To identify cluttering:

• First you must listen to nonstuttered speech of the speaker.
• Next, evidence for a fluency disorder (one that is not stuttering),  with use of excessive disfluencies, would be present in a speaker who meets all of the following criteria:

  • Does not sound "fluent," that is, does not seem to be clear about what he or she wants to say or how to say it.

  • Has excessive levels of "normal disfluencies," such as interjections and revisions.

  • Has little or no apparent physical struggle in speaking.

  • Has few if any accessory (secondary) behaviors

Having a Rapid and/or irregular speaking rate includes demonstration of the following:

• Talks "too fast" based on an overall impression or actual syllable per minute counts.
• Sounds "jerky."
• Has pauses that are too short, too long, or improperly placed.
• In addition, a person that is cluttering may or may not present with a number of symptoms that add support and evidence to the impression that a person is cluttering.

 Additional symptoms that assist with a cluttering diagnosis consist of the following:

• Confusing, disorganized language or conversational skills.

• Limited awareness of his or her fluency and rate problems.

• Temporary improvement when asked to "slow down" or "pay attention" to speech (or when being tape recorded).

• Mispronunciation or slurrring of speech sounds or deleting non-stressed syllables in longer words (e.g., "ferchly" for "fortunately").

• Speech that is difficult to understand.

• Several blood relatives who stutter or clutter.

• Social or vocational problems resulting from cluttering symptoms.

• Learning disability not related to reduced intelligence.

• Sloppy handwriting.

• Distractibility, hyperactivity, or a limited attention span.

• Auditory perceptual difficulties.

Motor Speech Disorders

Motor speech disorders include two primary categories, apraxia and dysarthria. In order to produce speech, every person must coordinate a range of muscles and muscle groups, including those controlling the larynx with the vocal cords, the lips, the tongue, the jaw and the respiratory system. Movements must be planned and sequenced by the brain and then put into motion in milliseconds with the correct timing and force of movement as the relevant muscles execute planned movements that create running speech. Difficulties in this process may result in apraxia or dysarthria, whether occurring in children as a part of development and in-born neurological differences or in adults as the result of injuries, neurological changes or illnesses.  

Apraxia of Speech:

• Apraxia involves a difficulty in planning, sequencing and/or coordinating relevant muscles or muscle groups for speech production.

Dysarthria: 

• Dysarthria is a disturbance in muscle control that results in weakness, slowness and/or incoordination of the oral articulators during speech production.  

Language Disorders

A language disorder is impaired comprehension (receptive language) and/or use (expressive language) of spoken, written and/or other symbol systems.

The disorder may involve:

• The form of language (phonology, morphology, syntax)
• The content of language (semantics)
• The function of language in communication (pragmatics)
• Deficits in any combination of the above 
• Prelinguistic communication (e.g., joint attention, intentionality, communicative signaling)
• Paralinguistic communication (e.g., gestures, signs, body language)
• Literacy (reading, writing, spelling)

Form of Language

The form of language consists of:

• • • Phonology is the sound system of a language and the rules that govern the sound combinations.
    • Morphology is the system that governs the structure of words and the construction of word forms.
    • Syntax is the system governing the order and combination of words to form sentences, and the relationships among the elements within a sentence.

Content of Language

Language content consists of:

• • • Semantics is the system that governs the meanings of words and sentences.

Function of Language

Language function contains:

• • • Pragmatics is the system that combines the above language components in functional and socially appropriate communication.      

Written Language Disorders and Dyslexia

A disorder of written language involves a significant impairment in fluent word recognition (i.e., reading decoding and sight word recognition), reading comprehension, written spelling, or written expression. A word recognition disorder is also known as dyslexia.

Written language disorders, as with spoken language disorders, can involve any of the five language domains (i.e., phonology, morphology, syntax, semantics, and pragmatics). Problems can occur in the awareness, comprehension, and production of language at the sound, syllable, word, sentence, and discourse levels.

• Sound-, Syllable-, And Word-level Difficulties:
  • Difficulty with phonological and morphological structure of words
  • Difficulty forming stable associations with the orthographic representations of words in print
  • Impaired reading decoding and written spelling skills

• Sentence- And Discourse-level Difficulties:
  • Difficulty recognizing discourse components
  • Difficulty using syntax and cohesive devices to represent relationships among ideas
  • Impaired reading comprehension and formulation of academic discourse (narrative and expository) and social communication

Children need strong knowledge of both the spoken and the written word in order to be successful readers and writers. Children with spoken language problems frequently have difficulty learning to read and write, and children with reading and writing problems often have difficulty with spoken language.

Cognitive Communication (Cognition)

Cognitive-communication disorders are problems with communication that have an underlying cause in a cognitive deficit rather than a primary language or speech deficit.

A cognitive-communication disorder results from impaired functioning of one or more cognitive processes, including the following:

• • • Attention
    • Memory
    • Perception
    • Insight and judgment
    • Organization
    • Orientation
    • Language
    • Processing speed
    • Problem solving
    • Reasoning
    • Executive functioning
    • Metacognition

These cognitive processes are not isolated abilities. They’re controlled by many cortical and subcortical structures within the brain. If the frontal lobe of the brain becomes damaged in a car accident, or a stroke happens in the right hemisphere, these cognitive processes can stop working properly. A person with a cognitive-communication disorder may have difficulty paying attention to a conversation, staying on topic, remembering information, responding accurately, understanding jokes or metaphors, or following directions.

Cognitive-communication disorders vary in severity. Someone with a mild deficit may simply have difficulty concentrating in a loud environment, whereas a person with a more severe impairment may be unable to communicate at all.

 Causes of Cognitive-Communication Disorders:

• Thirty-five to 44 percent of stroke survivors find themselves with cognitive impairments about three months after their strokes. About a third of these people experience impairments for a long time.
• Stroke is just one cause. A cognitive-communication disorder can also result from a traumatic brain injury (TBI), a brain infection, a brain tumor, or a degenerative disease such as multiple sclerosis, Parkinson’s disease, Alzheimer’s disease, or another form of dementia.
• Cognitive-communication disorders can occur alone or in combination with other conditions, such as dysarthria (slurred speech), apraxia (inability to move the face and tongue muscles correctly to form words), or aphasia (impaired language).

Voice    

Our voice is produced when air from the lungs passes through the vocal folds (vocal cords) in the larynx (voice box) causing the vocal folds to vibrate. This vibration produces a sound that is then modified and shaped by the vocal tract (throat, mouth and nasal passages). A voice problem or disorder can be caused by a problem in any part, or combination of parts, of this system.

Symptoms of a voice disorder can include:

• • hoarseness
  • roughness
  • breathiness
  • strained voice
  • weak voice
  • vocal fatigue
  • throat pain when speaking

Causes of these symptoms can include:

• • vocal nodules
  • polyps and cysts
  • muscle tension
  • spasmodic dysphonia
  • vocal fold paralysis
  • Parkinson's Disease and other neurologic disorders
  • laryngeal cancer
  • vocal overuse/misuse such as talking loudly in a classroom without amplification, or frequent yelling at sporting events and concerts

Dysphagia

Dysphagia is the medical term used to describe difficulty swallowing. Dysphagia can include difficulties with one or all of the four phases of swallowing.

Four Phases of Swallowing:

1. 1. Oral Preparatory -voluntary phase during which food or liquid is manipulated in the mouth to form a cohesive bolus—includes sucking liquids, manipulating soft boluses, and chewing solid food.
   2. Oral Transit - voluntary phase that begins with the posterior propulsion of the bolus by the tongue and ends with initiation of the pharyngeal swallow.
   3. Pharyngeal - begins with the initiation of a voluntary pharyngeal swallow which in turn propels the bolus through the pharynx via involuntary peristaltic contraction of the pharyngeal constrictors.
   4. Esophageal - involuntary phase during which the bolus is carried to the stomach through the process of esophageal peristalsis.

Feeding Disorders

Feeding disorders are problems with a range of eating activities that may or may not include problems with swallowing.  Feeding disorders can be characterized by one or more of the following behaviors:

• Avoiding or restricting one’s food intake (avoidance/restrictive food intake disorder [ARFID]; American Psychiatric Association, 2016)
• Refusing age-appropriate or developmentally appropriate foods or liquids
• Accepting a restricted variety or quantity of foods or liquids
• Displaying disruptive or inappropriate mealtime behaviors for developmental level
• Failing to master self-feeding skills expected for developmental levels
• Failing to use developmentally appropriate feeding devices and utensils
• Experiencing less than optimal growth (Arvedson, 2008)

Orofacial Myofunctional Disorders (OMDS)

Children, teenagers, and adults may suffer from OMDs. OMDS may interfere with normal growth and development of the muscles and bones of the face and mouth. OMDs may also interfere with how the muscles of the face and mouth are used for eating, talking, and breathing.  People who have an OMD may also have problems with talking, swallowing, and breathing through their nose. Some children push out their tongue when they talk, drink, or eat. This is called tongue thrusting or fronting, and it is one type of OMD.

Signs of an OMD may include the following:

• • • Someone who always breathes through the mouth or has difficulty breathing through the nose.
    • Limited tongue movement.
    • Eating may be messy or difficult. Keep in mind that it is normal for babies to stick their tongue out and push food out of their mouth. Over time, they do this less.
    • An overbite, underbite, and/or other dental problems.
    • The tongue pushing past the teeth, even when a person is not talking or using the tongue.
    • Difficulty saying some sounds, like "s" in "sun," "sh" in "ship," or "j" in "jump."
    • Drooling, especially beyond age 2.
    • Difficulty closing the lips to swallow.

Causes of an OMD

There is not a known, single cause of OMDs.

Some OMDs may be caused by these factors:

• • • Blocked nasal passages because of tonsil size or allergies. When the nasal passages are blocked, people may need to breathe through their mouth instead.
    • Anything that causes the tongue to be misplaced at rest or makes it difficult to keep the lips together at rest.
    • Poor sucking and chewing habits past the age of 3 years.

Auditory Habituation/Rehabilitation

A hearing disorder is the result of impaired auditory sensitivity of the physiological auditory system. A hearing disorder may limit the development, comprehension, production, and/or maintenance of speech and/or language. Hearing disorders are classified according to difficulties in detection, recognition, discrimination, comprehension, and perception of auditory information. Individuals with hearing impairment may be described as deaf or hard of hearing.

1. 1. Deaf is defined as a hearing disorder that limits an individual's aural/oral communication performance to the extent that the primary sensory input for communication may be other than the auditory channel.

   2. Hard of hearing is defined as a hearing disorder, whether fluctuating or permanent, which adversely affects an individual's ability to communicate. The hard-of-hearing individual relies on the auditory channel as the primary sensory input for communication.

Auditory Habilitation for Children

Treatment of hearing disorders in children is termed "Rehabilitation" because the focus is on restoring a skill that is lost. In children, a skill may not be there in the first place, so it has to be taught -- hence, the services would be "habilitative," not "rehabilitative."

Specific treatment services for children are individualized and dictated by the following aspects:

• • • the current age of the child
    • the age of onset of the hearing loss
    • the age at which the hearing loss was discovered
    • the severity of the hearing loss
    • the type of hearing loss
    • the extent of hearing loss and the age at which amplification was introduced.

The aural rehabilitation plan is also influenced by the communication mode the child is using. Examples of communication modes are auditory-oral, American Sign Language, total communication, Cued speech, and manually coded English.

Aural habilitation in children may include the following aspects in treatment sessions :

• • • Training in auditory perception. This includes activities to increase awareness of sound, identify sounds, tell the difference between sounds (sound discrimination), and attach meaning to sounds. Ultimately, this training increases the child's ability to distinguish one word from another using any remaining hearing. Auditory perception also includes developing skills in hearing with hearing aids and assistive listening devices and how to handle easy and difficult listening situations.
    • Using visual cues. This goes beyond distinguishing sounds and words on the lips. It involves using all kinds of visual cues that give meaning to a message such as the speaker's facial expression, body language, and the context and environment in which the communication is taking place.
    • Improving speech. This involves skill development in production of speech sounds (by themselves, in words, and in conversation), voice quality, speaking rate, breath control, loudness, and speech rhythms.
    • Developing language. This involves developing language understanding (reception) and language usage (expression) according to developmental expectations. It is a complex process involving concepts, vocabulary, word knowledge, use in different social situations, narrative skills, expression through writing, understanding rules of grammar, and so on.
    • Managing communication. This involves the child's understanding the hearing loss, developing assertiveness skills to use in different listening situations, handling communication breakdowns, and modifying situations to make communication easier.
    • Managing hearing aids and assistive listening devices. Because children are fitted with hearing aids at young ages, early care and adjustment is done by family members and/or caregivers. It is important for children to participate in hearing aid care and management as much as possible. As they grow and develop, the goal is for their own adjustment, cleaning, and troubleshooting of the hearing aid and, ultimately, taking over responsibility for making appointments with service providers.

The most debilitating consequence of onset of hearing loss in childhood is its disruption to learning speech and language. The combination of early detection and early use of amplification has been shown to have a dramatically positive effect on the language acquisition abilities of a child with hearing loss. In fact, infants identified with a hearing loss by 6 months can be expected to attain language development on a par with hearing peers.

Auditory Rehabilitation (AR) for Adults 

Rehabilitation for adults focuses on communication skills training and may range from improving articulation to managing conversation. Treatment may be delivered in a group setting.

Areas of focus may include the following:

• • • Articulation
    • Communication strategies
    • Conversational repairs
    • Pragmatics
    • Self-advocacy
    • Voice (e.g., resonance, loudness)

Speechreading

Speechreading refers to processing speech using visual information, such as movements of articulators, facial cues, and gestures. Including speechreading in an AR plan of care supports the idea that "cross-modal stimulation from optical and acoustic events contribute to multisensory enhancement in speech perception" (Lansing, 2014, p. 253). Training may be provided to both the speech reader (i.e., listener) and the communication partner (i.e., talker). For example, the speech reader may engage in perceptual practice activities while the talker learns to modify speech and use proactive behaviors to reduce miscommunications. See Wickware (2014) for a description of four approaches to speechreading training: analytic, synthetic, pragmatic, and holistic.

Central Auditory Processing Disorder (CAPD)

Central auditory processing disorders are deficits in the information processing of audible signals not attributed to impaired peripheral hearing sensitivity or intellectual impairment. This information processing involves perceptual, cognitive, and linguistic functions that, with appropriate interaction, result in effective receptive communication of auditorily presented stimuli. Specifically, CAPD refers to limitations in the ongoing transmission, analysis, organization, transformation, elaboration, storage, retrieval, and use of information contained in audible signals.

CAPD may involve the listener's active and passive (e.g., conscious and unconscious, mediated and unmediated, controlled and automatic) ability to do the following:

• • • attend, discriminate, and identify acoustic signals
    • transform and continuously transmit information through both the peripheral and central nervous systems
    • filter, sort, and combine information at appropriate perceptual and conceptual levels
    • store and retrieve information efficiently; restore, organize, and use retrieved information
    • segment and decode acoustic stimuli using phonological, semantic, syntactic, and pragmatic knowledge
    • attach meaning to a stream of acoustic signals through use of linguistic and nonlinguistic contexts

Augmentative and Alternative Communication (AAC)

Augmentative and Alternative Communication (AAC) is an umbrella term that encompasses the communication methods used to supplement or replace speech or writing for those with impairments in the production or comprehension of spoken or written language. AAC includes all of the ways we share our ideas and feelings without talking. We all use forms of AAC every day. For instance, you use AAC when you use facial expressions or gestures instead of talking or you use AAC when you write a note and pass it to a friend or coworker. We may not realize how often we communicate without talking.  

People with severe speech or language problems may need AAC to help them communicate. Some may use it all of the time. Others may say some words but use AAC for longer sentences or with people they don’t know well.  AAC can help in school, at work, and when talking with friends and family.  There are two main types of AAC.

Types of AAC

1. Unaided systems and aided systems - You may use one or both types. Most people who use AAC use a combination of AAC types to communicate.
   • 1. Unaided Systems - You do not need anything but your own body to use unaided systems. These include gestures, body language, facial expressions, and sign language.
     2. Aided Systems - An aided system uses some sort of tool or device. There are two types of aided systems, either basic or high-tech.
        • Basic Systems -  A pen and paper is a basic aided system. Pointing to letters, words, or pictures on a board is a basic aided system.
        • High-Tech Systems -Touching letters or pictures on a computer screen/tablet that speaks for you is a high-tech aided system. Some of these speech-generating devices, or SGDs, can speak in different languages.