Introduction, aetiology, Epidemiology, Clinical features, Theories, Scale, Diagnosis, Assessment, management of stuttering. Fluency: continuity, smoothness, rate, and effort in speech production. All speakers are disfluent at times. They may hesitate when speaking, use fillers (“like” or “uh”), or repeat a word or phrase. These are called typical disfluencies or non-fluencies (ASHA - American Speech-Language-Hearing Association). Types of fluency disorders Stuttering Cluttering Normal Non-fluency Stuttering (Stammering) the most common fluency disorder, is an interruption in the flow of speaking characterised by specific types of disfluencies, including: Prolongations unnatural stretching of a sound (e.g., “Ssssssssometimes we stay home”); Repetitions of sounds, syllables, and monosyllabic words (e.g., “Look at the b-b-baby,” “Let’s go out-out-out”); Hesitations usage of fillers (“like” or “uh”), Blocks inability to initiate speech sounds/difficulty getting a word/pausing in between words CLASSIFICATION OF STUTTERING: DEVELOPMENTAL STUTTERING: It is initially noted in children between three and eight years of age Approx. 75 % of pre-schoolers with developmental stuttering spontaneously recover within 4 years. Normal non fluency: As children pass through normal language development they will be disfluent in certain period when compared to others.   ACQUIRED STUTTERING: Neurogenic stuttering: usually follows a neurologic event, such as traumatic brain injury, stroke, or other brain damage. stuttering occurs at the beginning of the words and the secondary behaviours are more obvious than with acquired stuttering. Cause: Cerebrovascular accident (stroke), with or without aphasia, Head trauma, Ischemic attacks (temporary obstruction of blood flow in the Brain) Signs and symptoms: Repetitions, Excessive levels of normal disfluencies , Extraneous movements Psychogenic stuttering: It is rare and usually occurs in adults with a history of psychiatric problems following a psychological event or emotional trauma; there may be no other known aetiology. Causes: Depression, Emotional responses to traumatic events, Anxiety Signs and symptoms: Rapid repetitions of initial sounds Epidemiology: The prevalence of stuttering over the whole population was 0.72%, with higher prevalence rates in younger children (1.4–1.44) and lowest rates in adolescence (0.53). Male-to-female ratios ranged from 2.3:1 in younger children to 4:1 in adolescence, with a ratio of 2:1 across all ages according to ASHA In India it is estimated that approx. 10% of cases with communication disorders may have stuttering according to AIISH. Aetiology: A variety of factors may influence stuttering events, although the etiology of the condition is unclear Possible contributing factors include cognitive processing abilities, genetics, gender of the patient, and environmental influences.

1. STUTTERING

2. Introduction
Etiology
Epidemiology
Clinical features
Theories
Scale
Diagnosis
Assessment
management
Case Presentation

3. Fluency: continuity, smoothness, rate, and effort in speech production.
All speakers are disfluent at times. They may hesitate when speaking, use
fillers (“like” or “uh”), or repeat a word or phrase. These are called typical
disfluencies or non-fluencies (ASHA - American Speech-Language-Hearing
Association).
Types of fluency disorders
• Stuttering
• Cluttering
• Normal Non-fluency

4. STUTTERING
• Stuttering (Stammering) the most common fluency disorder, is an interruption in
the flow of speaking characterized by specific types of disfluencies, including:
• Prolongations unnatural stretching of a sound (e.g., “Ssssssssometimes we stay
home”);
• Repetitions of sounds, syllables, and monosyllabic words (e.g., “Look at the b-b-
baby,” “Let’s go out-out-out”);
• Hesitations usage of fillers (“like” or “uh”),
• Blocks inability to initiate speech sounds/difficulty getting a word/pausing in
between words
I’m (Pause) sorry

5. CLASSIFICATION OF STUTTERING:
• DEVELOPMENTAL STUTTERING:
It is initially noted in children between three and eight years of age
Approx. 75 % of pre-schoolers with developmental stuttering spontaneously
recover within 4 years.
Normal non fluency:
As children pass through normal language development they will be disfluent in
certain period when compared to others.

6. ACQUIRED STUTTERING:
• Neurogenic stuttering: usually follows a neurologic event, such as traumatic
brain injury, stroke, or other brain damage.
stuttering occurs at the beginning of the words and the secondary behaviours are
more obvious than with acquired stuttering.
Cause:
Cerebrovascular accident (stroke), with or without aphasia, Head trauma, Ischemic
attacks (temporary obstruction of blood flow in the Brain)
Signs and symptoms:
Repetitions, Excessive levels of normal disfluencies , Extraneous movements

7. • Psychogenic stuttering: It is rare and usually occurs in adults with a history of
psychiatric problems following a psychological event or emotional trauma;
there may be no other known aetiology.
Causes:
Depression, Emotional responses to traumatic events, Anxiety
Signs and symptoms:
Rapid repetitions of initial sounds

8. The prevalence of stuttering over the whole population was
0.72%, with higher prevalence rates in younger children (1.4–
1.44) and lowest rates in adolescence (0.53).
Male-to-female ratios ranged from 2.3:1 in younger children to
4:1 in adolescence, with a ratio of 2:1 across all ages according
to ASHA
In India it is estimated that approx. 10% of cases with
communication disorders may have stuttering according to
AIISH.

9. • A variety of factors may influence stuttering events, although the
etiology of the condition is unclear
• Possible contributing factors include cognitive processing abilities,
genetics, gender of the patient, and environmental influences.
• Genetic factors: Growing evidence supports a link between genetics and
stuttering.
In a study of twins, nearly 70 percent of the variance in stuttering was
attributable to genetics, with the remainder attributable to environmental
influences.

10. Cognitive Factors:
• Recent studies have shown that some adults who stutter have different cognitive
processing abilities than those who do not stutter.
• One small study reported that adults who stutter have longer reaction times than
fluent speakers when presented with increasingly complex cognitive tasks. In
persons who stuttered, these cognitive processes involved more use of the right
hemisphere of the brain than was used in fluent speakers.

11. Environment:
• Environmental influences, such as stressful social situations, talking on the
the telephone, and negative experiences associated with speaking, may
also contribute to the persistence of stuttering.
• Anxiety levels of persons who stutter are specific to the communication
situation.
(AFP journal)

14. Primary stuttering behaviours:
Repetitions, pauses, hesitations and prolongations..
• Disordered breathing, including antagonism between abdominal (belly) and thoracic
(upper chest) respiratory muscles; complete cessation of breathing, and interrupting
exhalation with inhalation.
• Disordered vocal folds, including high levels of muscle activity or muscle tension; poor
laryngeal too late or holding tension too long; and poor coordination of laryngeal
muscles, e.g., incompatible contractions of opposing muscles.
• Disordered articulation, including dysfunctions of the lips, jaw, and tongue in stuttering.
In general, stutterers place their articulators in the right positions (in contrast to other
speech disorders such as lisping, in which individuals form incorrect sounds), but at times
times the movements go wrong.

15. Secondary stuttering behaviours:
• Physical movements
• Gross (large) muscle movements
• Avoidance of feared words
• Postponement of a feared word
• Interjected "starter" sounds and words
• Repeating a sentence or phrase
• Vocal abnormalities to prevent stuttering
• Looking away from the listener
• Articulating an unrelated sound

16. Feelings and Attitudes:
• A person’s feelings can be as much as a part of the disorder of
stuttering as his/her speech behaviours. Feelings may precipitate
stutters, just as stutters may create feelings.
• In the beginning, a child’s positive feelings of excitement or negative
feelings of fear may result in repetitive stutters that he hardly notices.
• Then, as he/she stutters more frequently, he may become frustrated or
ashamed because he can’t say what he wants to say - even his own
name - as smoothly and quickly as others.

17.  Theoretical Perspectives about Constitutional Factors in
Stuttering.
 Theoretical Perspectives on Developmental and
Environmental Factors
 An Integration of Perspectives on Stuttering

18. THEORETICAL PERSPECTIVES ABOUT
CONSTITUTIONAL FACTORS IN STUTTERING
Stuttering as a Disorder of Brain Organization:
Many studies reports that areas in the left hemisphere are specialized for
processing language and that the right hemisphere is subservient to the left,
playing a minor role in the production and comprehension of language.
One early theory of stuttering suggested that it is caused by lack of
hemispheric dominance.

19. Stuttering as Reduced Capacity for Internal Modeling :
Constitutional factors in stuttering was advanced by Megan and Peter
Neilson. The Neilson's proposed that the repetitions of beginning stutterers
are the result of a deficit in their ability to create and use “inverse internal
models of the speech production system” (Neilson & Neilson, 1987).
It is an “inverse” model because it transforms or inverts sensory targets (i.e.,
heard speech sounds) into the motor commands needed to produce them.
As infants learn to produce the sounds they hear, they constantly use and
refine their sensory-motor model for speech. They plan a word or sentence
in terms of what it should sound like (the target) and then rely on their
sensory-motor model to generate the motor movement commands that
will produce the speech targets they are trying to hit.

20. Internal model is continues to develop as a child’s speech and language skills
mature and the speech production system changes with age. The internal model’s
motor commands are sent to the muscles of the speech production system, whose
coordinated contractions produce the acoustic output that result in a planned
utterance. Concurrently, ongoing planning and feedback of this process are fed
into the modeling circuitry.
This theory attempts to account only for the core behaviors of early stuttering, that
is, repetitions and prolongations. According to the theory, repetitions and
prolongations result from inadequate transformations of sensory targets,
transformations that should generate the motor commands for speech.

21. THEORETICAL PERSPECTIVES ON DEVELOPMENTAL
AND ENVIRONMENTAL FACTORS
It represents three different conceptualizations of how developmental or
environmental stresses (or both) result in stuttering.
• Diagnosogenic Theory:
As applied to stuttering ,a theory that attributes the disorder to misdiagnosis of
normal disfluency in a young child, the resultant anxiety exacerbates the
disfluency and establishes stuttering as a disorder
• Demands and capacities model:
The basic premise of demands and capacities model is that the onset and
development of stuttering is related to mismatch between a child’s capacities
(motor, linguistic, cognitive and emotional) self-imposed or externally driven
speech demands (time pressure, pragmatic issues and situational influences)
• Communicative Failure:
The specificity of the remaining view (i.e., communicative failure) lies
somewhere in between the two others.

22. AN INTEGRATION OF PERSPECTIVES ON STUTTERING
A Two-Stage Model of Stuttering:
Many years ago, a child psychiatrist who stuttered, Charles Bluemel, observed
that stuttering begins in most children as repetitions, of which they are hardly
aware and to which they don’t react
Bluemel (1932) called the beginning behaviors “primary” stuttering and the
later reactions “secondary” stuttering.

24. Neuro imaging scans:
EEG
ECT Scan
SPECT Scan
PET Scan
fMRI

25. • Case History
• File Review
• Parent/Teacher Report
• Speech Fluency Assessment
• Speech Sample
• Assess/Screen All Other Areas
• Individual Strengths/Strategies

26. 1) Case History:
• Helps in collecting background information.
• To know, does the student have any significant medical history?
• Is there a family history of stuttering? When did the student start
stuttering?
• How long has the student been stuttering?
• This can be super helpful when looking at risk factors.
2) File Review:
• It’s helpful to take a look at past evaluations/treatment notes (if they’re
available).
• To have insight into the student’s progress over time and what worked
(and what didn’t work) in therapy.

27. 3) Parent/Teacher Report:
To collect information from the parent and/or teacher to understand how
stuttering is impacting the student and/or what that looks like across a variety of
contexts.
4) Speech Fluency Assessment:
The Stuttering Severity Instrument (SSI-4 or 3) is a norm-referenced stuttering
assessment.
This assessment provide information about the severity of the stuttering.
5) Speech Sample:
For more informal data, can collect speech samples across a variety of contexts
(e.g., when telling a story, when speaking with peers) and track the number of
disfluencies (about 200 words/more than 200 syllables in 120 seconds of time).

28. 6) Assess/Screen All Other Areas:
To find about
• Articulation, oral-motor function, language, voice, social language, hearing
7) Individual Strengths/Strategies:
Based on all of the information that we collected, what can we leverage in
therapy? What are the student’s strengths? Has he/she implemented some
strategies independently?

29. One of the most widely used standardized procedures for assessment of the overt aspects
of stuttering is the Stuttering Severity Instrument (Riley, 1972).
The instrument rates three aspects:
(1) Percent stuttered syllables (in older versions: percent stuttered words); Two quantities
are needed to obtain the percentage of stuttered syllables (%SS) for both judgment
procedures: 1) counts of all syllables spoken; and 2) counts of syllables that are
stuttered. Riley advocated obtaining these separately and this was done for both
judgment conditions ( i.e., Frequency)
(2) Estimated length of three longest blocks The duration score is the time, in seconds, of
the three longest stuttering events in the sample. For each judgment condition, once
the average duration was obtained it was converted to a scale score using the reader’s
Table in the computation form (Riley, 1994)

30. 3. Perceptual scaling of associated behaviors: distracting sounds, facial grimaces, head
movements, movements of extremities (i.e., Physical concomitants).
• Distracting Sounds -This category includes any non-speech sounds that accompany the
stuttering. Riley gives as examples noisy breathing, whistling noises, sniffing, blowing and
ResearchGate Journal

33. Treatment Approaches:
 Shaping stutter-free speech
 Modification Therapy
 Integrating stutter-free shaping and modification
Therapy
 Mechanical Intervention Devices
 Counselling (adult stutterer)
 Approaches for children
 MIDVAS

34. (1) Shaping stutter-free speech:
Initial therapy targeting stutter-free speech at one or two word
level, when stutterer is successful the SLP increases the complexity
of utterance
Singing
Slowed & Prolonged Speech
Slowed speech and Stretched syllable technique
Coral speaking
Light contact Method (Light articulatory contact - LAC)

35. (2) Modification Therapy:
SLP modify the moments of stuttering by introducing
Relaxation Techniques And decreasing stress, effort
and struggle.
(3) Integrating stutter-free and modification therapy:
The SLP benefits from both types of therapies

36. (4) Mechanical Intervention Devices:
Some of these devices resemble a normal hearing aid.
Best candidate for such a therapy is one who has
a. stuttered for a significant period of time
b. continue to struggle with stuttering
c. has found speech shaping and other traditional therapies
ineffective.
DAF (Delayed Auditory Feedback)
Use of a Metronome (Rhythmic Speech)

37. (5) Counselling:
Counselling does not mean ‘lecturing’ the stutterer rather refers to
providing an opportunity to explore, verbalize and express feelings
about himself, his problems, about his/her therapy about the process
of changing, about expectations and fears about the future
(6) Approaches for children:
Environmental Manipulation
Direct work with the child
Desensitization therapy
Parent-child interaction therapy
Fluency-shaping behavioural therapy
Parent and family Counselling

38. (1) Environmental Manipulation
General excitement level in the home
Fast paced activity
Communication stress
Competition for talking time
Social and emotional deprivation
Sibling rivalry
Excessive speech interruptions
Talking attempts aborted by family members
(2) Direct work with the child
Directly working on the speech symptoms in a caring and supportive
manner

39. (3) Desensitization Therapy:
This therapy attempts to increase gradually the child’s tolerance to stress
The SLP starts with play activity that reduces disfluency to its lowest
level, The SLP keeps as many stress factors as possible out of the activity.
A typical desensitization session involves,
Eliminating talking altogether
Not asking direct questions
Silent parallel play
Maintaining a slow pace of interaction
Maintaining a low excitement level
While not playing avoiding stressful themes

40. (4) Parent-child Verbal Interaction Therapy:
The assumption is that childhood disfluencies develop in responses
to parent-child verbal interaction
The SLP will observe such behaviour in a non-formal setting then
can mirror image the process doing just the opposite of what the
parent did following instances of disfluency
When child’s disfluency reduced to 1% or less, parent are
introduced into the therapy to learn more positive forms of verbal
interaction with their child and to use them at home.
(5) Parent and family counselling:
Identifying and changing some family behaviour patterns, by
making them understand hoe their behaviour and feelings interact
with the child
Sometimes the SLP feel child’s speech within boundaries of normal

41. (6) Transfer and maintenance:
This is a very critical phase of therapy. In this regard after
reducing stuttering to a minimal level the person practices these
new skills in a non-clinical environment
This is called transfer and maintaining these new skills is called
maintenance
(7) Follow – up:
Follow up is very important to help maintaining the new learned
skill
Initially on alternate days, then once after every, then a week,
then once a week, then once a month for few months

42. MIDVAS
It is a Stuttering modification therapy. Given by Charles Van riper (1973)
1) Modification- important underlying factor throughout the treatment
process.
2) Identification- it is important to know as much as possible about the
behaviour.
3) Desensitization- reduction of stress associated with stuttering.
4) Variation - provides the individual alternative stuttering methods to increase
speaking ability
5) Approximation - alternation of stuttering behaviour in the direction of
“normal” fluency.

43. Cancellation : stops, pauses.
Pull out : alternation of stuttering behaviour as it occurring.
Preparatory set : anticipation of stuttering Behaviour and modification
before it occurs.
6) Stabilization - individual becomes a confident communicator.
Strength of this program
Focuses on the whole person
encourages an internal focus of Control
Easy clinical application

45. Strategy How to do it Why it works
Breathy speech Add extra air in your voice It reduces tension
Blending continuous
phonation
Keep your voice going all the time. Blend sounds
together smoothly. Let your mouth and voice glide
through your words.
Reduces tension, slows down your speech.
Easy start
Easy onset
Start the first word of your thought with a very relaxed,
slow voice. The rest of your sentence will be normal.
Reduces tension.
Easy stuttering Let yourself stutter. Repeat the first syllable of your
word or phrase on purpose with a relaxed mouth and
throat.
Easy stuttering reduces tension and makes
stutters shorter and less noticeable.
Eye contact If you are having a tough time with your speech keep
looking at the person you are talking with but don't
look away.
Helps the other person know that you are
still talking to them and can keep them from
interrupting.
Finger strategy run your finger under the words while you read them
out loud. Keep your voice with your finger.
Produces full story helps with pacing and
helps keep your mouth and your eyes
moving together.

46. Strategy How to do it Why it works
Long starts The first word of each is sssslow and
sssstretchy.
Reduces tension.
Light articulatory contacts Speak using soft sounds on consonants. Your
lips and tongue barely touch when you talk.
Reduces tension.
Phasing take breaks for breathing and pausing. Add
a pause in between ideas when you are
about to stutter or when you need to think
about what to say next.
Reduce rate. Gives extra time for your
mouth to make the sounds. Also helps at
expression to reading or speaking.
Pull out/slide Freeze on the stutter. Relax the part of your
speech machine that is tight or pushing.
Keep going with the words.
Reduces tension.
Speed scale On a speed scale of 1 to 10 aim for “the
zone” which is around a 3 or 4, 1-2 is too
slow and 6 and above is too fast.
Reduces rate. Going in a steady rate helps
keep your mouth and your brain together.
Stretchy words Stretch your words out loooooong,
especially the words which are making you
stutter.
Reduces rate, reduces tension.
Time-out When you start to stutter, pause for 3
seconds relax your mouth and begin again.
Reduces rate and reduces tension.

47. A COMPLETE MANAGEMENT
HAPPENS WITH TEAM APPROACH

48. REFERENCES:
Barry guitar; Stuttering : an integrated approach to Its Nature and treatment
David ward; Stuttering and Cluttering (frame work of understanding and treatment)
Wingate, M.E. “Recovery From Stuttering.” Journal of Speech & Hearing Disorders
Starkweather, C.W. Fluency and Stuttering. Englewood Cliffs: Prentice-Hall
American Academy of Family Physician journal: AFP journal
https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwirnv2S5aD4AhVQ8XMBHX4SBuMQFnoECAoQAQ&ur
=https://www.aafp.org/afp/2008/0501/p1271.html&usg=AOvVaw013XfQTkIBb0SGq4M-sV-c
ResearchGate:
https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwjd9tnA4aD4AhXL1zgGHVjxDmQQFnoECAoQAQ&url=http
s://www.researchgate.net/publication/335126628_Assessment_of_Stuttering_Severity&usg=AOvVaw2gS8wGT18Hr5U6Ms48QC-r