FLUENCY DISORDERS

FLUENCY DISORDERS
KUNNAMPALLIL GEJO JOHN, MASLP
KUNNAMPALLIL GEJO JOHN
Definition : Fluency & Disfluency Factors affecting fluency Dimensions of fluent speech Theoretical constructs in fluency development
FLUENCY
DEFINITION: Fluency refers to the effortless production of long continuous utterance at a rapid rate, be it the first or second language. - Stark Weather (1980) Stark Weather (1987) considered fluency as a multidimensional behavior and the dimension of fluency are: - continuity or smoothness of speech - rate of speech -effort a speaker makes in producing speech (Stark Weather 1981) -rhythmic structures (Stark Weather 1981)
According to Perkins (1977), FLUENCY is a barometer for the entire speech system, with its limits apparently set by adequacy or performance of the other dimensions of speech. According to Kunnampallil Gejo (2009), Fluency refers to the uninterrupted production of long continuous smooth utterance at a minimum rate of the language which is legible for the speaker and listener.
DYSFLUENCY:
The term dys denotes pathology or abnormal . Dysfluency abnormal instances of fluency failure, ie ; those most closely associated with stuttering. Dysfluencies have been broadly defined as including all instances of broken words ( ie; part-word, syllable, or sound repetitions or prolongations) and/or fluency disruptions associated with excess tension or struggle.
In contrast, Disfluency has been proposed as the appropriate term for normal non-disfluencies. Disfluencies or normal non-fluencies are considered to include - silent - non tense pauses - interjections - revisions - word or phrase repetitions without indications of stress or struggle.
Normal disfluencies have been cataloged by several authors, and there is general agreement among them as to what constitutes disfluency. Eight commonly used categories of disfluency are: * part-word repetition * single-syllable word repetition * multisyllabic word repetition * phrase repetition * interjection * revision- incomplete phrase * prolongation * tense pause
Some of the major distinguishing features that differentiate normal disfluency from stuttering are # the amount of disfluency # the number of units of repetitions & interjections # type of disfluency, especially in relation to the age of the child.
Johnson (1961) classified the following types of speech behavior as disfluencies: 1. Interjection 2. Part-word repetition 3. Word repetition 4. Phrase repetition 5. Revisions 6. Incomplete phrases 7. Broken words 8. Prolonged sounds
1.
Interjection of sounds, syllables, words or phrases: This implies extraneous sounds uh, er hmm; - extraneous words such as well which are distinct, from sounds and words associated with the fluent text or with phonemes included one or more units or repetition of the interjected material; For eg: uh-uh-uh are each counted as one instance of interjection . The number of times the interjection is repeated within each instance is also noted, uh-uh is an example of an interjection; repeated once and uh-uh-uh is an example of an interjection repeated twice.
2. Part- word repetition:

This category has repetitions of parts of wordsthat is syllables and sounds. Within each instance of repetition the number of times the sound or syllable is repeated is counted; box-buy involves one unit of repetition and guh-guh involves two units. This does not distinguish between sound and syllable repetitions. eg: ruh-ruh-ruh cuhcome, ba-ba-baby & a-bou bout
3. Word repetition:
This category includes repetitions of whole words including words of one syllable. Both the number of instances and number of repetition units within each instance are counted. I-I-I, was- was & going are samples of instances of word repetition; the first involves two units of repetition and each of other two involves two unit. A word repeated for emphasis as in very, very clear is not counted as a disfluency.
4. Phrase repetitions: This category includes repetitions of two or more words. eg: I was I was going 5.Revisions : Instances of revision include those in which the context of a phrase is modified, or in which there is a grammatical modification. Change in pronounciation of a word is also counted as a revision. eg: I was- I am going
6. Incomplete phrases : - one which in the thought or context is not completed and - which is not an instance of phrase repetition. eg: she was- and after she got there he come. 7. Broken words : - Words which are not completely pronounced and which are not associated with any other category, or - in which the normal rhythm of the word is broken in a way that definitely interferes with the smooth flow of speech are characterized by this category. eg: I was g-(pause)- going home.
8. Prolonged sounds : This category includes sounds judged to be unduly prolonged. If a sound is prolonged twice, it is counted both as a prolonged sound and a part- word repetition.
FACTORS AFFECTING FLUENCY

Several factors - continuity - rate - effort - rhythm - physiological framework of fluency - motor and linguistic factors - language complexity - grammatical categories - sexs - situation and - environmental factors seems to affect fluency.
1. CONTINUITY: Pauses whether filled or unfilled are a common feature of speech. We pause on the average every 4.8 words and our perception of speech seems to be more continuous than the reality of it. Presumably, this happens because we focus on the content of communication we listen to the ideas and not contribute to these ideas is filtered out by our perceptual mechanism. This is not to say that pauses near convey information, but the information sometimes they convey has to do with the process of communication or with the speakers level of uncertainty rarely with the content (Stark Weather 1987).
There has been a presumption from the earliest days of research in this area, that the pauses were occasions on which language was being formulated and although it seems likely that this is true for some pauses it may not be true for all pauses. In support of the idea that the two types of pauses are different in kind, Clark notes that idiosyncratic pauses convey no information, and tend to be overlooked and concludes that conventional pauses are information bearing elements of sentences.
2. RATE OF SPEECH: This is the rate in which continuous syllables can be produced as a function of speed of articulatory movement and the degree of coarticulatory overlap. ( Gay,1978; Stark Weather, 1981). Females produce utterance that are more variable in rate and longer utterances and they are more fluent than males ( Malecot, Johnson and Kizzias, 1972). Rate depends on the type of syllables produced, CCV and CVC syllables are produced at a faster rate than VCC syllables.
3. EFFORT: Speech being produced effortlessly, is a characteristic of fluent speech ( Stark Weather,1987). The two types of efforts are : - mental effort or concentration where the thoughts are focused on the content rather than on the processes of utterances and - muscular effort, where the effort provides a flow of air, opens and closes the glottis and moves the tongue, lips, jaw, velum and pharynx (Stark Weather,1987).
Among the speech sounds, stops & fricatives require more effort than nasals and glides. (Malecot,1955; Worth & Sakuda,1966). Effort is consequently related to rate, stress & duration of speech sounds. Effort of mind & effort of muscle are both aspects of fluency. It is difficult to measure the former.
4. RHYTHM: Rather than being a dimension of fluency, rhythm seems to promote or enhance fluency. Speech rhythm serves fluency by making it easier for us to talk faster. It does this in several ways- unstressed syllables are shorter and thus require less time. Martin(1972) says that rhythmic patterning carries a heavy information load in ordinary connected speech
5. PHYSIOLOGICAL FACTORS: Dejoy & Gregory (1985) indicated that during the later preschool years, children become more accomplished in the symbolic/ motoric selection. They added that the forward flow of speech becomes relatively more automatic The reduction in frequency may well reflect increased temporal precision and control and simplification of the control process (Sharkey & Polkins, 1985). Van riper (1971) indicated that disruption of proper programming of the physiological movements necessary for fluent speech causes stuttering. Spatial & timing co-ordination are essential physiological aspects of fluency (Stark Weather,1987).
6. MOTOR FACTORS: Muscles that contract during a speech will receive a high frequency neural impulses at the proper movement. Muscles which are relaxed will receive a low frequency neural impulse. The capacity to relax antagonist muscles has more to do with frequency than the capacity to contract agonist muscles, which is proved in stutters (Freeman & Ushijima,1978). Along with the mass and stiffness of the peripheral mechanism, certain neural mechanisms also have an important influence on the timing of movements.
7. LANGUAGE MATURITY: It is one of the important factor which is related to fluency. Increased ability in phonology, semantics, syntax & pragmatic knowledge influence fluency. As these abilities grow, sentences become longer and more complex.
8. LANGUAGE COMPLEXITY: Analysis of language samples of Haynes & Hood (1978) who studied 20 males & 20 female children between 5 to 6yrs supported that language influences dysfluency especially in the complex modeling condition. Significant increase in word repetition, revision, incomplete phrase and dysrhythmic phonations occurred in the complex modeling situation.
9. GRAMMATICAL CATEGORY: It is found that the frequency of occurrence of both unfilled & filled pauses is more before *content words than function words (Fagen,1982). The words following filled pauses are difficult to predict and filled pauses occur mainly before words which are highly uncertain. Filled pauses are much more common at the *beginning of clauses than within clause (Hawkings,1971) and - they tend to occur *before longer and more complex sentences (Smith & Lallijee, 1974).
10. SEX: Some studies have indicated that males show greater disfluencies than females in the age groups 2-6yrs (Haynes & Hood,1977; Yairi,1981; Wexler & Mysak,1982).
11. ENVIRONMENTAL FACTORS: The person to whom the child is speaking is also an important factor which influences fluency. It has been found that the child speaks more fluently with a puppet than with an experimenter.
DIMENSIONS OF FLUENCY
There are several dimensions of fluency. Stark weather (1987) defines speech fluency in terms of continuity, duration, co-articulation & effort.
1) Continuity : - refers to the degree to which syllables & words are logically sequenced as well as the presence or absence of pauses. If the semantic units follow one another in a continual flow of information, the speech is interpreted as fluent.
If however, the units of speech fail to flow in a logical sequence, information does not flow. Despite a continual flow of sound & the absence of pauses, the speech is not thought of as fluent.
Another aspect of continuity pauses The pauses in the sequence of speech can be viewed from several perspectives. Clark (1971) differentiates pauses as conventional & idiosyncratic. Conventional pauses are used by speakers to signal a linguistically important event. Idiosyncratic pauses reflect hesitation or uncertainty on the part of the speaker. These pauses indicate a decision- making process concerning upcoming word, choice, style or syntax.
Pauses also have been considered as unfilled or filled. Unfilled pauses are characterized by a silence lasting longer than ~250millisec (Goldman-Eisler,1958). This duration is suggested as a convenient threshold for normal silent intervals during fluent speech, since normal word junctures rarely exceed this duration ( eg: the juncture necessary to distinguish night rate from nitrate).
Filled pauses are characterized by essentially meaningless sounds such as ah, or, uh & um. Whether the speech is considered fluent depends on many other features including the frequency of these pauses along with the occurrence of other aspects of fluency.
Rate of speech also signals the perception of fluency. If a speaker is producing a lengthy utterance, the rate of speech is likely to be more rapid (Malecot, Johnston & Kizziar, 1972). Speaker is producing speech at a slow rate, everything else being equal, the speaker is not likely to be evaluated as being non-fluent. Conversely, speaker is producing speech at a very rapid rate, he or she is not likely to be evaluated as being produced. Although the rate of production is one aspect of fluency, it does not appear to be a primary dimension. The flow of speech & information is based not only on rate, but on a combination of many factors, particularly the ease of production.
2) Duration of speech segments relates closely to the co-articulation of the segments. The duration of the consonants & vowels of a language varies considerably with speech rate, phonetic & linguistic context. For eg: stressed syllables are longer than unstressed ones (Umeda, 1975). Sound segments are longer at the initiation & termination of syllables, words & phrases (Fowler,1978).
Segment durations are dramatically influenced by - position in the syllable (initial consonants are longer than syllable-final consonants), - length of the word (segments are shorter with longer words) & - sentence length (segments are shorter during longer sentences) [Huggins, 1978] Co- articulatory effects are greater when the speech rate is increased ( Gay,1978).
Co-articulatory effects contribute to the timing & smoothness of speech. In fluent speech, articulatory movements between the sounds, syllables & words are done with ease. The transitions are smooth & there is a continuous flow of overlapping sounds.
The final dimension of fluency Effort. Starkweather (1987) distinguishes two types of effort: - effort associated with linguistic planning - effort associated with muscle movement. Clinically, it may be that the listeners perception of effort, in combination with the other dimensions of fluent speech production, is the common indicator of fluent speech. As Starkweather suggests, Fluent speech is effortless in two distinct ways : It requires little thought & it requires little muscular exertion.
Fluent speech is characterized by little attention being paid to the process of production; speaking is automatic. The thought process in fluent speech takes relatively little time, while the execution of speech takes somewhat longer. Fluent speech is characterized by little sensation of opposition or constriction of airflow.
On the other hand, people who stutter are at the opposite end of the continuum of effort. Greater effort is associated with all the following : - greater contact between articulators - greater impedance between the flow of air & the structures of the vocal tract, beginning with the vocal folds - greater subglottic air pressure With the speaker producing speech in this fashion, it is likely that speech will be judged as non-fluent.
DEVELOPMENT OF FLUENCY
Initially, the speech of children lacks fluency. When demand from the society increases to produce fluent speech, fluency increases. It increases with increase in age. If the child is capable of meeting the demands of the society , the speech is fluent. If the child is incapable of meeting societal demands, dysfluent speech is produced.
1) Development of Speech Continuity: Continuity is a factor affecting fluency. Kowal & Sabin(1975) studied 168 normal children from KG to 12th grade. The most common dysfluencies are, * pauses * repetitions * false starts * parenthetical remarks
Frequency of dysfluencies did not change from KG to 12th grade children. So it was understood that frequency could not be taken as a tool for assessing fluency. It was noticed that false starts, repetitions & pauses decreased steadily from KG to 12th grade. There was a sudden increase in false starts at 4th grade.
- It was speculated that, at this age as children were formally trained in terms of grammatical knowledge, they might be over conscious of their speech and would try to apply their grammatical knowledge. Hence, a number of false starts would occur. Parenthetical remarks increased steadily from KG to 12th standard. This was believed to give continuity to their speech. There was no developmental trend seen in terms of dysfluencies.
Dejoy & Gregory (1975) studied children between 3 - 5yrs of age. They reported that repetitions of words, phrase, part word, incomplete phrases & dysrhythmic phonation were more commonly seen in 3yr old than 5yr old. Yairi (1981) studied 33 normal children of 24-33mths . He found that part word & small word repetition are most commonly seen in young children.
Revisions & incomplete phonations did not show any developmental trend 2-4yrs. Repetitions, tense phrase, dysrhythmic phonation decline steadily from 2-4yrs. Interjections & repetitions of words & phrases decline steadily with increase in age.
2) Development of Rate: Rapid rate is an aspect for fluency . Many researchers have studied rate by the following ways, # measuring duration of pauses # measuring syllables per second # measuring duration of segment (length of utterances) From the studies, it has been reported that, there is a clear cut trend in development.
Duration of pauses: Kowal & Sabin (1975) reported that development of rate shows there is a dramatic development of fluency. There is a rapid change in terms of duration of pauses from KG 2nd grade children. They also observed that males have longer unfilled pauses as compared to females & duration of pauses decrease with increase in age.
Syllables per second : Kowal & Sabin (1975) reported that there is a short increment in terms of syllables per second from KG 2nd grade children. It is leveled at 4th grade. A step increase is seen between 4th & 8th grades. From 8th grade onwards, not much increase is seen. Therefore, rate of speech in terms of syllables/sec shows a steady increase in school age children. Black & Walker (1950) reported an adult speaker is able to speak at an average of 5-6 syllables/sec. Armster (1984) reported that, rate of speech show a clear cut developmental trend in pre-school children.
Duration of Segment/Utterance : Speaking slowly & precisely is one of the characters of children speech. The speech of an adult is faster & has many overlapping co-articulatory movements. Studies have shown that, duration of segment increase with increase in age. With increase in age, there is a decrease in duration of individual sounds, so fluency of speech increases.
Duration of /s/ in word initial position is brief in 7yr old as compared to 5yr old children. Duration of sound is shorter in longer utterances/words, unstressed words & sounds in initial position. Smith (1984) reported that 2-4yrs is the critical period for duration of segment/utterances.
3) Development of Ease of Speech: Effortless speech is an influential factor in maintaining fluency. The effort may be mental or physical: - the amount of time an individual takes in planning an utterance reflects in the amount of mental effort required in fluent speech. - the amount of time taken in executing an utterance reflects on the amount of physical/muscular effort required for fluent speech production.
In younger children, rate is slower indicating that the amount of time spent in executing an utterance is more .therefore, physical effort is more. In adults, rate of speech is faster because time spent in executing an utterance is less & so, physical effort is less. Presence of pauses & repetitions indicates the amount of time spent in planning & therefore, mental effort taken with increase in age, there is a decrease in mental & physical effort. Co-ordination: articulators & the 3 systems are important for production of fluent speech.
Researchers have shown that, DDK rate increases in age & continues till 18-20yrs. Fast rate of repetition shows steady increase from 6-19yrs. Variability seen in terms of speech production usually decreases with increase in age. Researchers have shown that, good speech motor control capacity like adults is acquired from 8-12yrs. They also found that as the nervous system develops till adolescent speech motor development also takes place till that time.
To summarise childrens speech becomes increasingly fluent as they mature. As the fluency increases children also learn to deal with lapses of fluency, such as discontinuous in more sophisticated. The growing capacity to talk more is due to increasing demands for fluent speech, the demands placed on children by the people they communicate with and by themselves. Most children show increased co-articulatory undershoot, utterances and useless effort in talking. Hence, all elements of fluency seems to grow.
Growth of fluent speech comes from several areas. There is increasing control over the movements of the vocal tact. This control develops in several ways. First, there is growth in the childs ability to react rapidly to stimuli. Second, there is an increase in the childs ability to co-ordinate the simultaneous movements of different parts of the vocal tract. Third, the ability to plan and then execute a sequence of movements.
Another capacity comes from rhythm. The sense of rhythm develops and makes it easier for a child to anticipate the movement of speech production. one of the growing demands is the child's development of language skills. Increased syntactic, semantic, phonologic & pragmatic knowledge contributes to this demand for fluency. As the childrens syntax develops, their sentences become longer & structurally more complex.
Because, the length of utterance is correlated with the rate of speech, the children must deal with a demand to increase the speed with which the vocal tract parts move. As the childs knowledge of the rules of phonology increases they become interested in using longer words & phrases and more difficult combination of sounds to express intentions. Childs pragmatic knowledge also grows and this also places a demand on the fluency of speech. The speech of young children is characterized by a spout of anxiety at 2 or 3yrs of age, their speech is a verbalization of their current thought or activity. With increased maturity speech becomes more controlled and directed to more specific purposes. Growth in pragmatics seems to diminish the spout anxiety of childrens speech.
It is not only the rules of language but also the people whom the child communicates place demands on them. These people include parents, sibling etc. Children have a tendency to use speech & language that is similar to that used by those they are talking to- when parents talk to their children using sophisticated language, syntactically complex and with an advanced vocabulary, the children try to use the same form. Some children do not develop the capacity for fluent speech as rapidly as others, and at times the demand for fluency made by their environments are too much for them to handle. When this is the case, fluent speech breaks down..
These frequent episodes as likely to cause the children to try harder- to get words out faster particularly words that have been produced discontinuously to struggle with them, forcing and pushing with increased air pressure and to tense the speech musculature so that is stiff, slow moving, un co-ordinated and tremulous. This is likely to slow the rate at which such children produce information. During the period of development of speech behavior, to child learns how to talk semi automatically. When the patterns of struggle tension and emotional reaction have become habitual and semi-automatic stuttering has developed
INDIAN STUDIES RELATED TO DEVELOPMENT OF FLUENCY: Naga Poornima (1990) studied Kannada speaking normal children between the age range of 3-4yrs. Story telling & picture description were used. Dysfluencies noticed were pauses, repetitions, false starts & parenthetical remarks. Unfilled pauses, false starts were observed maximally during picture description. Number of unfilled pauses decreased between 3-3.8yrs, but sudden increase was seen from 3.8-3.10yrs after which there was a decline between 3.104yrs. No developmental trends were observed.
Repetitions increased from 3-3.4yrs but decreased from 3.6-4yrs. False starts were seen more in the picture description tests in the word initial position. Parenthetical remarks were seen more in story-telling tasks. Frequency increased from 3-3.4yrs, decreased from 3.4-3.8yrs and again increased from 3.8-4yrs.
Indu (1990) : Studied Kannada speaking children between 4-5yrs of age. Connected speech was used. Pauses, repetitions & parenthetical remarks were most commonly seen in content words than in function words. They were seen more in the initial position
Yamini (1990) : Studied Kannada speaking normal children of 56yrs. She used 6 sets of picture cartoons Common dysfluencies observed are : # filled & unfilled pauses # audible inspirations # parenthetical remarks # false starts # repetitions These dysfluencies occurred more before nouns than other grammatical categories and is observed more in initial position.
Rajendraswamy (1991): Studied Kannada speaking normal children between the age range 6-7yrs. 6 sets of panchatantra stories were used. He found that increase in % age of dysfluency was present from 6-6.6yrs. Common dysfluencies observed were : * filled pauses * false starts * repetitions * parenthetical remarks
Less common dysfluencies were : * audible inspirations * broken words * unfilled pauses More dysfluencies seen on/ before nouns, verbs, conjunctions & interjections. Less commonly seen on/before prepositions & adverbs. Dysfluencies were reported to be mainly in initial position.
Sharma (1991) : Studied dysfluencies in Hindi speaking normal children between 6-7yrs. Percentage of dysfluencies decreased from 6-6.4yrs. Maximally occurring dysfluency was unfilled Filled pauses were seen maximally between 6.6-6.8yrs. Parenthetical remarks were seen between 6.6-6.8yrs Prolongations were less commonly seen. No definite pattern was seen in the occurrence of dysfluencies. Dysfluencies were present mainly in the initial position.
DEVELOPMENT OF DYSFLUENCY
Froeschels (1921) depicted the development of stuttering as a process in which simple repetitions by progressive stages became more rapid, irregular, forced, and finally inhibited under the pressure of some penalty. Bluemel (1932) termed the incipient stage of the disorder primary stuttering.
He noted that it often consisted of the repetition of the first word or syllable of the sentence and that it frequently had a tendency to disappear and return repeatedly over a period of months or years. He described secondary stuttering as characterized by the childs consciousness of the impediment, physical effort, the use of starters, synonyms and other attempts to control or conceal stuttering, anticipation, above all fear of letters, words, people & speech situations.
Van Ripers Four Tracks :

Van Riper (1982) offered a descriptive scheme which placed particular stress on the variability of stuttering
Track 1 - Van Riper found the symptoms to consist initially of effortless, unhurried repetitions of syllables & words, marked by extreme fluctuations & long remissions. - Onset was gradual. - As the disorder progressed the repetitions became more rapid & irregular, & there appeared in sequence prolongations, tension & forcing with intermittent evidence of concern on the part of the child, associated movements, word & situation fears & avoidance.
Track 2 Children who were late in beginning to talk, the stuttering was said to take the form of rapid, irregular syllable & word repetition from the beginning. Later, silent intervals, revisions, & interjections appeared, & the pattern took on many aspects of cluttering. Thereafter the pattern changed relatively little. Word & sound fears were generally mild & tended to develop late.
Track 3 Sudden inability to speak, or complete blockage. Very soon this was followed by severe forcing & struggle, breathing abnormalities, signs of frustration, associated facial & other tensions, fear & avoidance. In most cases the severe struggle reactions abated after a while & followed first by prolongation & then by syllable repetition.
Track 4 Children who were reported to have begun to stutter rather suddenly with repetition of phrases, words, & later syllables. They tended to stutter openly with few avoidances & showed little changes in their stuttering over the years.

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KUNNAMPALLIL GEJO JOHN, MASLP

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2. Part- word repetition:

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FACTORS AFFECTING FLUENCY

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Van Ripers Four Tracks :

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