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.

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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 non-

reflexively, 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.

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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 one’s 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 two’s 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

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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 child’s 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 individual’s 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

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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

don’t 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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