"Spontaneous" late recovery from stuttering: Dimensions of reported techniques and causal attributions.

PURPOSE: (1) To survey the employed techniques and the reasons/occasions which adults who had recovered from stuttering after age 11 without previous treatment reported as causal to overcome stuttering, (2) to investigate whether the techniques and causal attributions can be reduced to coherent (inherently consistent) dimensions, and (3) whether these dimensions reflect common therapy components. METHODS: 124 recovered persons from 8 countries responded by SurveyMonkey or paper-and-pencil to rating scale questions about 49 possible techniques and 15 causal attributions. RESULTS: A Principal Component Analysis of 110 questionnaires identified 6 components (dimensions) for self-assisted techniques (Speech Restructuring; Relaxed/Monitored Speech; Elocution; Stage Performance; Sought Speech Demands; Reassurance; 63.7% variance explained), and 3 components of perceived causal attributions of recovery (Life Change, Attitude Change, Social Support; 58.0% variance explained). DISCUSSION: Two components for self-assisted techniques (Speech Restructuring; Elocution) reflect treatment methods. Another component (Relaxed/Monitored Speech) consists mainly of items that reflect a common, non-professional understanding of effective management of stuttering. The components of the various perceived reasons for recovery reflect differing implicit theories of causes for recovery from stuttering. These theories are considered susceptible to various biases. This identification of components of reported techniques and of causal attributions is novel compared to previous studies who just list techniques and attributions. CONCLUSION: The identified dimensions of self-assisted techniques and causal attributions to reduce stuttering as extracted from self-reports of a large, international sample of recovered formerly stuttering adults may guide the application of behavioral stuttering therapies.

Exploring the Neural Bases of Primary Muscle Tension Dysphonia: A Case Study Using Functional Magnetic Resonance Imaging.

Primary muscle tension dysphonia (pMTD) is a voice disorder that occurs in the absence of laryngeal pathology. Dysregulated activity of the paralaryngeal muscles is considered the proximal cause; however, the central origin of this aberrant laryngeal muscle activation is unclear. The Trait Theory (Roy and Bless, 2000a,b) proposed that specific personality traits can predispose one to laryngeal motor inhibition and pMTD, and this inhibition is mediated by a hyperactive "behavioral inhibition system (BIS)" composed of limbic system structures (and associated prefrontal connections). This case study used functional magnetic resonance imaging to detect brain activation changes associated with successful management of pMTD, thereby evaluating possible neural correlates of this poorly understood disorder. METHOD: A 61-year-old woman with moderate-to-severe pMTD underwent functional magnetic resonance imaging scans before and immediately after successful treatment using manual circumlaryngeal techniques. Experimental stimuli were blocks of repeated vowel production and overt sentence reading. RESULTS: Significantly greater activation was observed pre- versus posttreatment in all regions of interest during sentence production, that is, periaqueductal gray, amygdala, hypothalamus, anterior cingulate cortex, hippocampus, dorsolateral prefrontal cortex, Brodmann area 10, and premotor and inferior sensorimotor cortex. CONCLUSIONS: Our findings are compatible with overactivation of neural regions associated with the BIS (cingulate cortex, amygdala, hypothalamus, periaqueductal gray) and motor inhibition networks (eg, [pre-]supplementary motor area) along with the dorsolateral prefrontal cortex and medial prefrontal cortex. Heightened input from limbic regions combined with dysfunctional prefrontal regulation may interfere with laryngeal motor preparation, initiation, and execution thereby contributing to disordered voice in pMTD.

Fluency adaptation in speakers with Parkinson disease: a motor learning perspective.

PURPOSE: Fluency adaptation is characterised by a reduction in stuttering-like behaviours over successive readings of the same speech material and is an effect that is typically observed in developmental stuttering. Prominent theories suggest that short-term motor learning associated with practice explain, in part, fluency adaptation. The current investigation examined the fluency adaptation effect in a group of speakers with Parkinson disease (PD) who exhibited stuttering-like disfluencies. METHOD: Individuals with PD (n = 21) and neurologically healthy controls (n = 19) read a passage five times. Per cent syllables stuttered was measured and calculated for each reading passage. RESULT: Participants in the PD group exhibited significantly more stuttering-like disfluencies than control speakers. Twelve individuals in the PD group exhibited at least three per cent syllable stuttered on at least one reading. Statistical trends revealed that the subgroup of individuals with PD who stuttered exhibited a significant reduction in stuttering moments over the five successive readings. CONCLUSION: A significant fluency adaptation effect was observed for the group of speakers with PD who exhibited stuttering-like disfluencies. Results of the current study are discussed within the framework of the motor learning hypothesis of fluency adaptation.

Quantification and Systematic Characterization of Stuttering-Like Disfluencies in Acquired Apraxia of Speech.

PURPOSE: The purpose of this article is to quantify and describe stuttering-like disfluencies in speakers with acquired apraxia of speech (AOS), utilizing the Lidcombe Behavioural Data Language (LBDL). Additional purposes include measuring test-retest reliability and examining the effect of speech sample type on disfluency rates. METHOD: Two types of speech samples were elicited from 20 persons with AOS and aphasia: repetition of mono- and multisyllabic words from a protocol for assessing AOS (Duffy, 2013), and connected speech tasks (Nicholas & Brookshire, 1993). Sampling was repeated at 1 and 4 weeks following initial sampling. Stuttering-like disfluencies were coded using the LBDL, which is a taxonomy that focuses on motoric aspects of stuttering. RESULTS: Disfluency rates ranged from 0% to 13.1% for the connected speech task and from 0% to 17% for the word repetition task. There was no significant effect of speech sampling time on disfluency rate in the connected speech task, but there was a significant effect of time for the word repetition task. There was no significant effect of speech sample type. CONCLUSIONS: Speakers demonstrated both major types of stuttering-like disfluencies as categorized by the LBDL (fixed postures and repeated movements). Connected speech samples yielded more reliable tallies over repeated measurements. Suggestions are made for modifying the LBDL for use in AOS in order to further add to systematic descriptions of motoric disfluencies in this disorder.

Discrimination and internalised feelings experienced by people who stutter in Jordan.

PURPOSE: This study investigated the internalised feelings and discrimination experienced by people who stutter in Jordan. METHOD: Five adult speakers who stutter were interviewed as a focus group. The participants were asked about their feelings related to stuttering and discrimination. The participants' responses in the focus group and items adapted from the extant literature formed the basis of a 20-item questionnaire. The questionnaire was administered to 20 additional adults who stutter to assess their internalised feelings about stuttering and their perceived rejecting behaviours (discrimination) associated with their impairment. RESULT: Feeling "annoyed" was the item that received the highest percentage of negative internalised feelings, followed by "embarrassed," "shame," "disappointed," "nervous, "sad," "pessimistic," "fearful," "worried" and "lonely." The results of the discrimination experiences indicated that "getting a leadership position" was the item that most people who stutter reported being worried about, followed by "participation in the classroom," "getting a job," "getting married," "being fully paid in their jobs," "teased," "promoted" and "renting a house." CONCLUSION: These findings provide further evidence of the universality that stuttering is more than the core surface features of speech, but also include aspects that exist below the surface such as negative internalised feelings and various discrimination experiences.

Formant transitions in the fluent speech of Farsi-speaking people who stutter.

PURPOSE: Second formant (F2) transitions can be used to infer attributes of articulatory transitions. This study compared formant transitions during fluent speech segments of Farsi (Persian) speaking people who stutter and normally fluent Farsi speakers. METHODS: Ten Iranian males who stutter and 10 normally fluent Iranian males participated. Sixteen different "CVt" tokens were embedded within the phrase "Begu CVt an". Measures included overall F2 transition frequency extents, durations, and derived overall slopes, initial F2 transition slopes at 30ms and 60ms, and speaking rate. RESULTS: (1) Mean overall formant frequency extent was significantly greater in 14 of the 16 CVt tokens for the group of stuttering speakers. (2) Stuttering speakers exhibited significantly longer overall F2 transitions for all 16 tokens compared to the nonstuttering speakers. (3) The overall F2 slopes were similar between the two groups. (4) The stuttering speakers exhibited significantly greater initial F2 transition slopes (positive or negative) for five of the 16 tokens at 30ms and six of the 16 tokens at 60ms. (5) The stuttering group produced a slower syllable rate than the non-stuttering group. CONCLUSIONS: During perceptually fluent utterances, the stuttering speakers had greater F2 frequency extents during transitions, took longer to reach vowel steady state, exhibited some evidence of steeper slopes at the beginning of transitions, had overall similar F2 formant slopes, and had slower speaking rates compared to nonstuttering speakers. Findings support the notion of different speech motor timing strategies in stuttering speakers. Findings are likely to be independent of the language spoken. Educational objectives This study compares aspects of F2 formant transitions between 10 stuttering and 10 nonstuttering speakers. Readers will be able to describe: (a) characteristics of formant frequency as a specific acoustic feature used to infer speech movements in stuttering and nonstuttering speakers, (b) two methods of measuring second formant (F2) transitions: the visual criteria method and fixed time criteria method, (c) characteristics of F2 transitions in the fluent speech of stuttering speakers and how those characteristics appear to differ from normally fluent speakers, and (d) possible cross-linguistic effects on acoustic analyses of stuttering.

Measuring Stuttering in Preschool-Aged Children across Different Languages: An International Study.

BACKGROUND/AIMS: Many speech-language pathologists (SLPs) are working in linguistically diverse communities and have to identify and measure stuttering in a language other than their own. The aim of the present study was to extend our understanding of how well SLPs can measure stuttering in other languages and to encourage collaboration between SLPs across cultures. METHODS: Speech samples consisted of seven preschool-aged children each speaking one of the following languages: Danish, English, French, German, Greek, Italian, and Persian (Farsi). The judges were classified in seven groups of SLPs (n = 170) each speaking one of the seven languages of the children and two more English-speaking groups. Each judge rated the severity of stuttering in each child using a 10-point scale. The study was conducted over the Internet. RESULTS: Overall, the judges' proficiency in a child's language was not systematically related to the variability and agreement of the severity ratings, accounting for maximally 4.6% of the variance. CONCLUSION: SLPs should not be overly concerned about the appropriateness of their severity ratings if they feel less proficient in the native language of the stuttering children. It may also be encouraging for beginning clinicians that the severity ratings were not systematically related to professional experience.

The role of language familiarity in bilingual stuttering assessment.

The aim of this study was to evaluate the ability of English-speaking speech-language pathologists (SLPs) to evaluate stuttering behaviour in two Spanish-English bilingual adults who stutter (AWS1 and AWS2). The English-speaking SLPs were asked to judge the frequency, severity, type, duration, and physical concomitants of stuttering in both languages of the two AWS. The combined results from the English-speaking SLPs were then compared to the judgements of three Spanish-English bilingual SLPs. Results indicated that English-speaking SLPs (1) judged stuttering frequency to be greater in Spanish than English for AWS1, and equal in Spanish and English for AWS2, (2) were more accurate at evaluating individual moments of stuttering for the English samples compared to the Spanish samples, (3) identified fewer and less severe stuttering behaviours than the bilingual SLPs in both languages, and (4) were accurate judges of overall stuttering severity in both languages. The results correspond to past research examining the accuracy of stuttering evaluations in unfamiliar languages. Possible explanations for the findings, clinical implications, and future research directions are discussed.

Behavioral treatments for children and adults who stutter: a review.

This paper provides a brief overview of stuttering followed by a synopsis of current approaches to treat stuttering in children and adults. Treatment is discussed in terms of multifactorial, operant, speech restructuring, and anxiolytic approaches. Multifactorial and operant treatments are designed for young children who stutter. Both of these approaches involve parent training and differ primarily in their focus on reducing demands on the child (multifactorial) or in their use of response contingent stimulation (operant conditioning). Speech restructuring and anxiolytic approaches are used with adults who stutter. Speech restructuring approaches focus on the mechanics of speech production, and anxiolytic treatments tend to focus on the symptoms and social and vocational challenges of stuttering. The evidence base for these different approaches is outlined. Response contingent therapy (for children) and speech restructuring therapy (for adults) have the most robust empirical evidence base. Multifactorial treatments for children and stuttering management approaches for adults are popular but are based on theoretical models of stuttering; the evidence base is not robust and tends to be inferred from work in areas such as cognitive behavior therapy and desensitization. Comprehensive, or holistic, approaches to treating stuttering are also discussed. Comprehensive approaches for treating stuttering in adults address both improved speech fluency and stuttering management.

Stuttering treatment for adults: an update on contemporary approaches.

This article provides a brief overview of historical and current approaches to stuttering treatment for adults. Treatment is discussed in terms of stuttering management approaches, fluency-shaping approaches, and combined approaches. The evidence base for these various approaches is outlined. Fluency-shaping approaches have the most robust outcome evidence. Stuttering management approaches are based more on theoretical models of stuttering, and the evidence base tends to be inferred from work using the approaches of cognitive behavior therapy and desensitization with other disorders such as anxiety. Finally, comprehensive approaches to treating stuttering are discussed, and several clinical methods are outlined. Comprehensive approaches target both improved speech fluency and stuttering management. Although it is presented that a comprehensive approach to stuttering treatment will provide the best results, no single approach to stuttering treatment can claim universal success with all adults who stutter.

Exploratory randomized clinical study of pagoclone in persistent developmental stuttering: the EXamining Pagoclone for peRsistent dEvelopmental Stuttering Study.

INTRODUCTION: Stuttering is a speech disorder in which the flow of speech is disrupted by repetitions, prolongation, and blocks of sounds, syllables, or words. No pharmacological treatments are approved for use in stuttering, and the most common form of treatment is speech therapy. This study was designed to assess the safety, tolerability, and effectiveness of pagoclone during 8 weeks of double-blind treatment followed by a 1-year open-label extension in patients who stutter. METHODS: An 8-week, multicenter, parallel-group, 2-arm, randomized (ratio 2:1 pagoclone-placebo), double-blind study with a 1-year open-label extension conducted at 16 US centers, including men and women aged 18 to 65 years who developed stuttering before 8 years of age. Twice-daily dosing with pagoclone (n = 88 patients) or matching placebo (n = 44 patients), with primary and secondary efficacy variables defined a priori, including Stuttering Severity Instrument Version 3 outcomes, clinician global impressions of improvement, and the change in the percentage of syllables stuttered. RESULTS: Pagoclone produced an average 19.4% reduction in percentage of syllables stuttered compared with 5.1% reduction for placebo. During open-label treatment, a 40% reduction in the percent syllables stuttered was observed after 1 year of treatment with pagoclone. The most commonly reported adverse event during double-blind treatment was headache (12.5% pagoclone patients, 6.8% placebo patients). DISCUSSION: Pagoclone was effective in reducing symptoms of stuttering and was well tolerated. In light of its favorable tolerability profile, as well as consistency of effects across multiple efficacy variables, pagoclone may have potential as a pharmacological treatment of stuttering. LIMITATIONS: The main limitation of this study was the adequacy of the number of subjects who participated because this study was conducted as a pilot investigation. Furthermore, as this condition waxes and wanes, the assessment of stuttering within the clinic setting may not be an adequate reflection of the stuttering of the patients within the community.

Revisiting speech rate and utterance length manipulations in stuttering speakers.

UNLABELLED: The goal of this study was to evaluate stuttering frequency across a multidimensional (2x2) hierarchy of speech performance tasks. Specifically, this study examined the interaction between changes in length of utterance and levels of speech rate stability. Forty-four adult male speakers participated in the study (22 stuttering speakers and 22 non-stuttering speakers). Participants were audio and video recorded while producing a spontaneous speech task and four different experimental speaking tasks. The four experimental speaking tasks involved reading a list of 45 words and a list 45 phrases two times each. One reading of each list involved speaking at a steady habitual rate (habitual rate tasks) and another reading involved producing each list at a variable speaking rate (variable rate tasks). For the variable rate tasks, participants were directed to produce words or phrases at randomly ordered slow, habitual, and fast rates. The stuttering speakers exhibited significantly more stuttering on the variable rate tasks than on the habitual rate tasks. In addition, the stuttering speakers exhibited significantly more stuttering on the first word of the phrase length tasks compared to the single word tasks. Overall, the results indicated that varying levels of both utterance length and temporal complexity function to modulate stuttering frequency in adult stuttering speakers. Discussion focuses on issues of speech performance according to stuttering severity and possible clinical implications. LEARNING OUTCOMES: The reader will learn about and be able to: (1) describe the mediating effects of length of utterance and speech rate on the frequency of stuttering in stuttering speakers; (2) understand the rationale behind multidimensional skill performance matrices; and (3) describe possible applications of motor skill performance matrices to stuttering therapy.

Fundamental frequency change during offset and onset of voicing in individuals with Parkinson disease.

SUMMARY: After years of treatment with the medication levodopa, most individuals with Parkinson disease (PD) experience fluctuations in response to their medications. Although relatively consistent perceptual voice improvements have been documented to correspond with these fluctuations, consistent quantitative data to support this finding are lacking. This mismatch may have occurred because most of this phonation research has centered on long-term phonatory measures (ie, across speaking samples and prolonged vowel tasks). The current study examined short-term phonatory behavior in individuals with PD, specifically examining fundamental frequency (F0) at the offset and onset of phonation, before and after a voiceless consonant. The F0 analysis at phonatory offset supported the conclusion that individuals with PD have difficulty with the rapid offset of voicing, and that they are stopping vocal fold vibration primarily through vocal fold abduction (without adding tension). The F0 analysis at phonatory onset revealed that all groups use some laryngeal tension at the initiation of voicing. The tension was lowest for the PD participants who were in their OFF medication state, and it was highest for the age-matched control participants and the PD participants in their ON medication states.

Intensive stuttering modification therapy: a multidimensional assessment of treatment outcomes.

Nineteen adults who stutter participated in a 3-week intensive stuttering modification treatment program (the Successful Stuttering Management Program [SSMP]). A series of 14 fluency and affective-based measures were assessed before treatment, immediately after treatment, and 6 months after treatment. Measures included stuttering frequency; the Stuttering Severity Instrument for Children and Adults, Third Edition (SSI-3); a self-rating of stuttering severity; the Perceptions of Stuttering Inventory (PSI); the Locus of Control of Behavior Scale; the Beck Depression Inventory; the Multicomponent Anxiety Inventory IV (MCAI-IV); and the State-Trait Anxiety Inventory. Statistically significant improvements were observed on 4 of the total 14 measures immediately following treatment and on 4 measures at 6 months posttreatment. Statistically significant improvements observed immediately posttreatment included scores on the SSI and the Struggle, Avoidance, and Expectancy subscales of the PSI. Sustained statistically significant improvements at 6 months posttreatment were observed only on client-reported perceptions of stuttering (the Avoidance and Expectancy subscales of the PSI) and 2 specific affective functioning measures (the Psychic and Somatic Anxiety subscales of the MCAI-IV). The SSMP generated some anxiolytic effects but was ineffective in producing durable reductions of core stuttering behaviors, such as stuttering frequency and severity. The discussion focuses on the strengths, weaknesses, and durability of the SSMP treatment approach.

Preliminary results of a functional MRI study of brain activation patterns in stuttering and nonstuttering speakers during a lexical access task.

UNLABELLED: An fMRI study examining lexical access and lexical generation in nine non-stuttering and seven stuttering speakers is presented. Lexical access was examined during a word description task that was presented auditorily while subjects "silently" thought of the target words. Participants alternated between four 30-s rest blocks and four 30-s "active" blocks. Activation patterns were assessed utilizing a standard subtraction paradigm, where the activation during the rest blocks was subtracted from the activation during the active blocks. High levels of variability characterized activation patterns within both speaker groups. Group comparisons using random effects statistical analyses did not identify significant differences between the groups when corrected for multiple comparisons. Analyses were subsequently conducted by comparing the trends in the group activation patterns between the speaker groups using fixed (corrected) and random effects (uncorrected) analyses. Non-stuttering control speakers activated primarily left hemisphere cortical speech and language areas while the stuttering speakers appeared to produce more bilateral activation. Discussion of these results focuses on the specific within- and between-hemispheric activation patterns and possible interpretations of these patterns. EDUCATIONAL OBJECTIVES: The reader will learn about: (1) issues related to interpreting brain activation findings in stuttering speakers; (2) the role and neurological substrates of lexical access during speech production in non-stuttering and stuttering speakers; (3) the basics of functional MRI; and (4) the brain activation areas involved during a silent lexical retrieval task in non-stuttering and stuttering speakers.

An evaluation of the effects of three laryngeal lubricants on phonation threshold pressure (PTP).

Clinicians frequently offer advice to performers and voice-disordered patients aimed ostensibly to manipulate the water content and/or viscosity of the mucus blanket covering the vocal folds. To evaluate the relative effects of three potential laryngeal lubricants on phonatory function (ie, water, Mannitol--an osmotic agent, and Entertainer's Secret Throat Relief (Kli Corp., Carmel, IN)--a glycerin-based product), phonation threshold pressure (PTP) was measured in 18 healthy, vocally normal female participants twice before (baseline) and then four times after 2 ml of each substance were nebulized. PTP is the minimum subglottal pressure required to initiate vocal fold oscillation, and the lowering of PTP is assumed to correspond to physiologically more efficient phonation and reduced phonatory effort. Over a 3-week period, participants were tested on three separate occasions (at 1-week intervals). On each occasion, a different nebulized treatment was administered. PTP for both comfortable and high fundamental frequency productions was measured using an oral pressure-flow system (Perci-Sars, MicroTronics Corp., Chapel Hill, NC). Analysis of the results revealed that Mannitol, an agent that encourages osmotic water flux to the luminal airway surface, lowered PTP immediately after its administration (ie, p = 0.071, for high-pitched productions only). However, the duration of its PTP lowering effect was less than 20 minutes. The other two substances did not demonstrate any significant postadministration effect on PTP.

Parkinsonian speech disfluencies: effects of L-dopa-related fluctuations.

UNLABELLED: The excess dopamine theory of stuttering (Wu et al., 1997) contends that stuttering may be related to excess levels of the neurotransmitter dopamine in the brain. As Parkinson's disease (PD) patients commonly exhibit changes in dopamine levels accompanied by changes in motor performance, the present study examined disfluency in PD patients to gain information on the role of dopamine in speech disfluencies. Nine PD patients with no history of developmental stuttering were recorded once before and twice after taking their morning medication (on separate days). They read a passage and produced a monologue. Within-word and overall speech disfluencies were calculated at each recording. Through motor testing, it was inferred that participants had relatively low dopamine levels before taking medication, and relatively high dopamine levels after taking medication. There were no group changes in disfluency levels when the low-dopamine and high-dopamine states were compared. There were, however, significant differences in percent disfluencies between the PD participants and age-matched controls. The results of this study do not strongly support the excess dopamine theory of stuttering. Rather, the disfluency changes exhibited by individual participants support a hypothesis that speech disfluencies may be related to increases or decreases in dopamine levels in the brain. EDUCATIONAL OBJECTIVES: The reader will learn about: (1). the characteristics of disfluent speech exhibited by speakers with Parkinson's disease. (2). The effect of L-dopa based medications on disfluencies of Parkinsonian speakers. (3). The complex role brain dopamine levels may play in disfluent speaking behavior.