Allison Zimmerman

CD 677: Disorders of Speech Production

Research Paper
December 3, 2013
Fluency Disorders: Considerations for Assessment & Treatment

A fluency disorder is an interruption in the flow of speaking characterized by atypical rate,

rhythm, and repetitions in sounds, syllables, words, and phrases. It may or may not be accompanied by
excessive tension, struggle behavior, and secondary mannerisms. Fluency disorders occur when speakers
produce one or more of the following, excessive core disfluency, excessive accessory disfluency, both
excessive core and excessive accessory disfluency, attempts to conceal or avoid disfluency (ASHA).
Fluency disorders include stuttering, language-based fluency disorder, cluttering, neurogenic stuttering,
and psychogenic stuttering. Stuttering is characterized by atypically frequent core disfluency with or
without attempts to avoid, escape, or conceal disfluency. A language-based fluency disorder is
characterized by atypically frequent production of accessory disfluency during production of otherwise
fluent speech. Cluttering is a fluency disorder involving excessive breaks in the normal flow of speech
that seem to result from disorganized speech planning, talking to fast or in spurts, or simply being unsure
of what one wants to say (St. Louis, 2013). Cluttering often occurs with stuttering. Neurogenic stuttering
is a fluency disorder in which a person has difficulty producing speech in a normal, smooth fashion
(Lawrence, 2013). It typically appears following an injury or disease to the central nervous system.
These injuries and diseases include stroke, head trauma, ischemic attacks, tumors, degenerative diseases,
drug related causes, and other diseases. Finally, psychogenic stuttering results in disfluent speech with no
medical factors or history of developmental stuttering present. This disfluency may be linked to
emotional stress or trauma (Lawrence, 2013).

Stuttering is the most common fluency disorder. It often co-occurs with other fluency disorders.

Incidence of stuttering is 4 to 5%. There is an increased incidence during preschool and early grade
school. Twenty-five percent of all children go through a stage in which they stutter during development.
Only five percent of these children are at risk in becoming persistent stutterers. The remaining twenty
percent will outgrow it. Prevalence is about one percent of individuals in the general adult population
who stutter and about three percent in preschoolers. Additionally, there is in increased prevalence in
people with traumatic brain injury, cerebral palsy, or cognitive disability. Also, prevalence is rare in the
hearing impaired population. Stuttering also rarely exists in individuals with cleft palate. School age
children who stutter are more than twice as likely to have another speech and/or language disorder. Other
common concomitant disorders include articulation disorders, phonology and/or language disorders.
There is an increased prevalence in males. The gender ratio is 4:1 males to females. There is an
increased incidence within families. 69 percent of individuals who stutter have positive family history of
stuttering. 88 percent of individuals who persist to stutter have a family history of stuttering. Thus, there
seems to be a genetic component to stuttering (Yairi & Ambrose, 2005). The onset of stuttering is almost
always before puberty and typically before the school-age years. Gradual onset of stuttering occurs 56
percent of the time, while sudden onset of stuttering occurs 44 percent of the time (Yairi & Ambrose,
2005).

Speech-language characteristics of individuals with fluency disorders are categorized by core and
accessory disfluencies. Core disfluencies often include part-word repetitions (e.g., sound and syllable
repetitions), dysrhythmic phonation (e.g., prolongations, broken words, tremor, and blocks), tense pauses,
and whole-word repetitions produced quickly and reflexively. Accessory disfluencies, also known as
typical or language-based disfluencies include whole-word repetitions produced slowly and nonreflexively, phrase repetitions, interjections (e.g., um, uh, like), revisions, circumlocutions, and unusual
pauses (Van Riper, 1971). A fluency disorder may also be associated with secondary behaviors that are
either escape behaviors which are attempts to get out of a moment of stuttering or avoidance behaviors
which are attempts to evade moments of stuttering. Awareness of disfluency also affects the condition.

Some individuals are aware of their disfluencies and others remain unaware. The majority of young
children are unaware of the problem, and children that are unaware do not demonstrate avoidance.
Awareness is usually paired with attempts to avoid stuttering. This is important to note during diagnosis.
Self-concept and self-esteem also impact disfluency disorders. If children have had negative experiences
in the past because they stutter, they may be more likely to attempt to avoid stuttering.

Some conditions seem to be associated with increased stuttering. These situations my include:
when excited, when upset, when having a lot to say, speaking on the phone, saying ones name, telling
jokes, speaking while trying to avoid or hide stuttering, or speaking to authority figures, unfamiliar
listeners, and in front of groups. Other conditions seem to be associated with decreased stuttering. Some
of these situations may include: singing, speaking to an animal, speaking when no one else is present,
whispering, speaking more slowly than usual, or imitating another person (Bloodstein, 1950).

Bluemel, Bloodstein, and Van Riper have each attempted to explain the development of
stuttering. Bluemel differentiates between a primary and secondary stage to explain the development of
stuttering where the primary stage reflects effortless repetitions and the secondary stage where disfluency
becomes a conscious physical struggle (Bluemel, 1957). Bloodstein breaks up the development to four
phases based on age. The dominant symptom in phase one is repetition. Disfluency tends to be episodic
which can cause trouble. Phase two is when the disorder becomes continuous. They child may have the
self-concept of a stutterer. Phase three is when stuttering comes in response to specific situations. This is
the phase where there is increasing avoidance of speech situations. Finally, phase four is when fear and
anticipations of stuttering become prominent. Avoidance of speech situations is evident in phase four
(Bloodstein, 1960). Van Riper explains development of stuttering in the terms of four tracks described by
onset and development. Track one is the most frequently occurring. Normally developing kids would fall
into the track one category. Track twos criteria is comparable to cluttering because the speed increases.
Track three involves an increase in frequency and signs of frustration. Track four is when the number of

instances and situations reaches a peak. Also, there are few avoidance behaviors or fears in track four
(Van Riper, 1982).

Fluency disorders can be a difficult thing to assess. This is due to the perceptual quality and
subjectivity in assessing disfluency. There are various assessment tools that exist for assessing
individuals with fluency disorders. Some of these tools include: fluency sample analysis which involves
collecting a speech sample, coding disfluencies, and analyzing the results; the Gregory & Hill
Classification System which differentiates between typically disfluent, borderline atypically disfluent, and
atypically disfluent/stuttering based on percentage of core and accessory disfluencies; the Van Riper
System of Guidelines for Differentiating Normal from Abnormal Disfluency which uses behaviors to
discriminate between normal fluency and stuttering; the Communication Attitudes Test which allows an
individual who stutters to reflect on his or her feelings toward their stuttering; the Iowa Scale of Severity
of Stuttering which classifies severity of stuttering based on percent of words, amount of tension, duration
of disfluency and secondary behaviors; and the Stuttering Severity Instrument (SSI) which uses
frequency, duration, and physical concomitants to classify stuttering.

Three popular approaches to fluency intervention include: (1) fluency building therapy, also
known as fluency enhancement therapy, (2) fluency shaping therapy, and (3) stuttering modification
therapy. Fluency building therapy is an approach commonly used with young children in which
environment alteration is implemented to indirectly enhance fluency. Factors that may trigger disfluency
are removed from a childs environment to provide a comfortable space for speaking. Furthermore,
experiences that activate fluency are provided. Fluency shaping therapy is a speak more fluently
approach to intervention in which fluent speech is programmed and reinforced in a clinical setting and
later generalized to an individuals daily environment. The third approach to intervention, stuttering
modification therapy, is a stutter more fluently approach in which strategies are taught to a client to

modify stuttering to a form that is less severe. It acknowledges the fact that stuttering will never
completely disappear, and focuses on helping a client cope with the disorder (Guitar & Peters, 1990).

In conclusion, we have discovered a lot about fluency disorders, but there is still much that we
dont yet know. Thus, research is ongoing today. We continue to search for the true cause of stuttering
even though it may never be found. We also continue to study differences between children who
spontaneously recover and those who persist to stutter. New intervention strategies for fluency disorders
also continue to emerge due to ongoing research. As a prospective Speech-Language Pathologist I look
forward to experiences with future fluency clients.

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