Transcript

Speech and Language

Vivian Sisskin
Instructor and clinical supervisor in the department of Hearing and Speech Sciences at the University of Maryland, College Park
Tuesday, June 27, 2006; 12:00 PM

Vivian Sisskin, was online Tuesday, June 27, at noon ET to discuss stuttering in children and other communication disorders. Sisskin is an Instructor and clinical supervisor in the department of Hearing and Speech Sciences at the University of Maryland, College Park.

Sisskin is an ASHA Board Recognized Specialist in Fluency Disorders and serves as Coordinator for ASHA's Special Interest Division 4, Fluency and Fluency Disorders. She has authored articles and continuing educational materials related to the treatment of school-age children who stutter. Her workshops and master classes focus on avoidance reduction therapy for stuttering, designing effective treatment plans for children who stutter, group therapy for adults and children who stutter, and self-help strategies. She maintains a private practice in the Washington D.C. area.

From The Post:

Another Side to Stuttering (Post, June 27)

The transcript follows.

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Vivian Sisskin: Hello and welcome!

I will try to address any questions related to diagnosis and treatment of children with speech and language disorders, but keep in mind, my areas of clinical expertise are stuttering and communication in autism spectrum disorders. I will certainly try to answer questions related to other or related communication disorders, however, for more information, you may find the Web site of the American Speech Language and Hearing Association helpful:

www.asha.org

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Ringwood, N.J.: How important is early intervention or do most toddlers grow out of stuttering?

Vivian Sisskin: Yes, most children who begin to stutter grow out of it. That is, approximately 80% of children who develop stuttering will "spontaneously recover" without any direct intervention. This observation has led many pediatricians to advise that parents ignore the problem as it will likely resolve on its own. However, there should be some specific qualifications related to spontaneous recovery. A team of researchers from the University of Illinois have studied a large group of children to see if there would be some generalizations related to which children would recover, and which children would develop a chronic stuttering problem (the 20%). While the results of the studies are compelling, we still cannot use them as a "crystal ball" because, as with most statistical information, we can't apply it to any one child. We can however, talk about "risk" factors related to chronicity. More boys will spontaneously recover than girls; recovery generally occurs within 18 months of stuttering onset (for example,one should not wait for stuttering to disappear after 3-4 years of symptoms); Recovery from stuttering in a family member is a positive indicator for recovery for the child; strong early language skills are more often associated with recovery; and earlier onset (closer to 2 and a half) is a more likely recovery profile than an onset of for example, age 4.

Decisions for early intervention are based on a number of diagnostic factors, this being one of them. The extent to which the child is reacting to the stuttering behavior is another issue to consider.

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Silver Spring, Md.: Thank you for taking time for this chat. My niece has apraxia of speech. What are the causes of apraxia?

Vivian Sisskin: Apraxia of speech is a motor speech disorder characterized by difficulty planning and sequencing the motor movements necessary for speech. There is generally no associated weakness or paralysis of the lips, tongue, larynx, etc. In addition, the individual generally knows what he or she wants to say but cannot execute the movements. Sound errors are inconsistent and the individual often appears as if he or she is groping for mouth positions. In adults, apraxia can be the result of neurological impairment, particularly stroke, however in children, the disorder is called Developmental Apraxia of Speech and it often appears as highly unintelligible articulation. It is important that a qualified speech-language pathologist diagnoses DAS because it can be confused with other articulation and phonological disorders in children. DAS is associated with problems in the overall development of the child's language, particularly learning the rules that govern the use and sequence of speech sounds. Treatment usually takes the form of linguistic approaches and motor planning approaches or a combination of both. Linguistic approaches focus on the rules that determine how sounds and sound sequences are used. Motor planning approaches use principles of motor learning, helping the child to consistently and automatically produce sounds.

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Forest Grove, Ore.: My son is a young adult and has struggled with stuttering since he was 5. When he was an adolescent, his speech therapist urged him to attend a local stutters support group, but he adamantly refused and wanted nothing to do with the idea. He did not like to think of himself as a speech-impaired person. In one sense, he is in denial, but this seems to work for him. I have wondered if this may have actually helped him. He has always had jobs that require heavy public contact, by telephone and in person, and seems to do quite well with his speech - as long as no one mentions the "s" word! However, I have read that it is helpful for stutters to be open and up front about discussing their stuttering. What do you think?

Vivian Sisskin: I have learned that every person who stutters has a very different profile in terms of the behavioral characteristics of speech (the actual disfluency, and associated struggle behaviors... loss of eye contact, head movements, word substitution, use of filler words) and the emotional and thought processes that go along with the disorder. For some, self-acceptance as a person who stutter, including willingness to show stuttering, talk about stuttering, and getting out and talking, are necessities for recovery in adulthood and adolescence. For others,thinking about stuttering causes them to "spiral down" into a pattern of struggle. Treatment strategies need to be highly individualized in order for recovery to occur.

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Vienna, Va.: What is the best way to enhance speech for a mildly-impacted autistic 4 year old? He's verbal, he talks about his surroundings, toys, games, books, movies, but doesn't do back and forth/converse. What in your expert opinion, is the best way to help him? One-on-one speech therapy? ABA? VB? Also, can you pls. direct me to any resources? I'm a single mom with limited funds.

Thank you.

Vivian Sisskin: There is no one answer for every child. I had to make these kinds of decisions for my own child with autism. I tried to look at his communicative needs, for example, was he communicating only when he wanted something or was he communicating to get someone's attention, comment, question, show humor. I think that a good assessment will help determine what approaches will be effective. Treatment for a child who can talk ABOUT his environment and relay information about events in the past and future may do well with treatment that focuses on pragmatic language development, specifically conversational interaction, rules of conversation, ability to repair communication, rate of communication. These may all be more important than the actual length of the sentence he produces. I would examine both behavioral approaches (ABA, VB) as well as more semantic pragmatic approaches (Floortime)

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Falls Church, Va.: I am an adult stutterer. I have been to various speech therapies (e.g., fluency shaping) with mixed results. They seem to work for awhile and then "wear off" Are there any therapies out there that really work?

Vivian Sisskin: Of course, I would say mine (LOL), but I will address the question more seriously. From my perspective, fluency shaping therapies (ones that teach the person a new way of talking that is incompatible with stuttering)are effective if one can practice enough to make this a new habit... not only a new habit, but the "default" even in the face of fear of speaking, stress, anxiety, time-pressure, and shame. Approaches that teach the person who stutters to modify the moment of stuttering to promote a forward moving, efficient, comfortable speech pattern (even if it contains SOME disfluency) has better generalization, from my perspective. Again, this is my opinion. I feel that for adolescents and adults, the most important factor related to recovery is the ability to make good choices, reduce avoidance behavior, and problem solve independently. The fact of the matter is that the more one tries to NOT stutter, the more they will. Treatment strategies that lead to openness about stuttering, result in giving one permission to stutter, and consequently reduce the severity and frequency of disfluency.

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Forest Grove, Ore.: Thank you. I appreciate your insight on this. Another question - What is your opinion about devices such as "Speech-Easy" to help control or manage stuttering?

Vivian Sisskin: Many people are interested in the effectiveness of devices such as the Speech Easy, which was featured on television shows such as the Today Show and Oprah. This is not new technology.... the device is just much smaller and less visible in the ear. It works on the notion of DAF (delayed auditory feedback) and FAF (frequency altered feedback). One's own words/voice is amplified back into the ear. DAF involves a small delay, as if one were experiencing an echo on a cell phone. FAF alters the frequency of the input. There are currently some well respected studies in place to examine the effectiveness of devices such as these. It appears that the people who wear them are satisfied with them overall, regardless of how often they wear it. There are some problems that have been reported: the effect may wear off for some (adaptation); all sounds in the environment are amplified and this can be disconcerting; not all people who stutter will benefit from the effect of DAF and FAF. More study of the effectiveness of these devices is warranted before we know who will benefit, as the cost is steep.

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Silver Spring, Md.: My son who is 16 now has been doing speech therapy since he was 14. It started earlier, but we didn't get him treatment earlier. When he does it, he does well, but without it--he still stutters.

Will he always need the therapy?

Vivian Sisskin: I am seeing a number of questions related to adolescents who have been in treatment for quite a while with only limited generalization of treatment benefits. I will talk generally about this...

We have a problem in our profession, that is, not all speech language pathologist have had the academic course work, mentoring, and experience to treat stuttering with confidence. In the grand scheme of things, stuttering is a low incidence disorder, and most speech-language pathologists need to treat a wide variety of disorders and understand the communication needs of children with many diagnoses (autism; learning disability; augmentative communication; multicultural issues, etc). Most speech pathologists will tell you right up front that they are not experienced or confident in treating stuttering. While not always feasible, if it is possible, one should seek out a Board Recognized Specialist in Fluency Disorders, or a generalist who has a working knowledge of diagnostic and treatment issues in stuttering. See: www.stutteringspecialists.org.

That said, parents should be on top of the treatment plans for their children. Learn about the nature of stuttering! I am always amazed that parents know so little about the problem, yet if their child had diabetes or asthma, they would be more informed. Also, understand the overall goals of therapy (ask to see and understand the treatment plan). Children should not be working on the same goals "will improve speech fluency"; will reduce concomitant behaviors" for years with no results. Stuttering is a very treatable disorder. While the child may not end up 100% "Fluent", joy and comfort in communication, effectiveness as a speaker, a positive self-concept as a speaker, and an ability to manage moments of stuttering are very realistic goals.

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Washington, D.C.: I've stuttered since I was a child, and in my twenties received "air-flow" therapy, which treated stuttering as a problem of not allowing relaxed breath to carry the sounds forward. Emotional or psychological reasons for the stuttering were really not dealt with at all. I went from severe (most of my youth) to controlled, but only when I practiced it. I still need to remind myself of how to use it in times of stress. Funny how relaxing and simply breathing can be the most difficult thing to do.

Vivian Sisskin: Yes, I agree! I always tell my clients that when they are communicating comfortably, they will automatically relax and not interfere with their breathing (which is also a very automatic function). One adult who stutters told me, " I don't stutter because I am nervous, I am nervous because I stutter."

Personally, and this may end up being a bit controversial, I find "control" do be a "dirty" work in the process of recovery. From my perspective, people who stutter do better to "let go," not "control."  When we try to control speech, it implies some sort of contention between forces at work. This leads to tension, and eventually struggle, and shame that results in avoidance. As my mentor, Joe Sheehan from UCLA used to say, " Go ahead and do the thing you fear the most.. stutter!"

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Boston, Mass.: I recently read about a drug company undergoing trials for a anti-stuttering medicine and that stuttering may be a brain disorder more than anything. Can you comment on this?

Vivian Sisskin: There is currently a clinical trial of Pagaclone which is being tested in numerous sites around the country. While I don't know too much of the detail related to the outcomes (soon to be published), apparently this drug will cause fewer of the negative side effects experienced by other drugs that have tried for stuttering (ie. risperdal). The theory is that there is a dopamine connection in the problem of stuttering. I have heard several of the researchers speak about the outcomes of many of these studies, and the bottom line is that drugs appear to have the greatest potential in conjunction with speech therapy. The name of the drug company is Indevus, and you can find out more information on their Web site.

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Chantilly, Va.: Prof. Sisskin: Question from one of your very satisfied clients (you'll know who this is in a a second):

Do you recommend that children of adult stutterers get evaluated once they start speaking even if they show no signs of stuttering? My twins will be two in a month and they are talking nonstop.

Keep up the great work!

Vivian Sisskin: Thanks for making me laugh, Bob!

It might be worth noting for other readers that there is a genetic component to stuttering. The role of genetics is still being explored, but we do know that identical twins are more likely to have concordance for stuttering than fraternal twins, adoption studies show that it is not learned from parents, and there are published studies out of NIH (D. Drayna) studying method of transmission and candidate genes. I do counsel my adult clients that they have a greater chance of having a child who stutters, 20-30% or so, and they should look out for these things. However, I would wait for some clear symptoms.

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Fairfax Station, Va.: My almost 6-year-old son repeats words, ideas, and phrases but it does not interfere with his learning, so he has not been diagnosed as having a speech disorder. However, the problems communicating affect his relationships with his peers and to some extent, adults too, as many people stop listening to him or cut him off when he speaks. He is left handed, shy, strong-willed and very intelligent (remembers everything). Socially though, he has few friends and transitioning from one activity to another has always been a problem. How can I help him?

Vivian Sisskin: This is an important question because there are many communication disorders that mimic stuttering. Sometimes, difficulties in language formulation associated with specific language impairment may result in disfluency, but not necessarily stuttering. Also, there are other fluency disorders, cluttering for example, that may manifest themselves in disfluencies as well as symptoms of rapid speech rate, articulation errors, etc. Finally, some social language problems related to Asperger's Syndrome may also have speech disfluency as a characteristic. A thorough speech and language assessment can differentially diagnose these disorders.

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Rockville, Md.: Vivian - thank you for mentioning the Web site of the American Speech-Language-Hearing Association. The public can access information about various speech-language-hearing disorders at and can get contact information for qualified professionals.

Vivian Sisskin: I'll just post this as a public service...

Also, please visit the Web sites of the Stuttering Foundation of America, the National Stuttering Association, FRIENDS (association of children who stutter), and a wonderful website full of helpful and reliable information:

www.stutteringhomepage.com

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Herndon, Va.: I am adult stutterer and my son who is 4 years old is also stuttering intermittently.

He speaks my native language at home and also speaking English at Pre-school.

We took him for a free evaluation with the Loudon county public schools support facility and they say they see no development issues and not to be too concerned right now as he may outgrow it. What is your advice? Thanks.

Vivian Sisskin: Again, I would be cautious of advice about growing out of stuttering if your child has been stuttering for more than 2 years. There is no clear evidence that bilingual children have greater risk for stuttering.

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Vienna, Va.: I am a little frustrated by the apparent conflict in theories as to what causes or influences stuttering. Is this a neurological problem? A psychological problem? Both?

Vivian Sisskin: We STILL don't know for sure what causes stuttering, but we certainly know more than we did even 10 years ago. It is likely both genetic and neurological/physiological. There may be weakness in linguistic encoding as well as motor production associated with onset, and perhaps even a temperament factor, for example reactivity (still not clear), as was discussed in today's article on stuttering in the Health Section. However, this refers to what causes or triggers stuttering to begin. It is very important to note that the PROBLEM of stuttering in school age children and adults most often comes from the maladaptive coping strategies that people who stutter LEARN to do to deal with stuttering. Behaviors such as loss of eye contact during the moment of stuttering, other facial grimaces, long pauses, sentence abandonment, use of interjections (uh, um), and restarting entire sentences or even words are learned escape and avoidance strategies. They persist because they worked initially to help the person move through the stuttering, but eventually became habits used to avoid showing more basic or primitive forms of stuttering that we see in young children. A large psychological component accompanies the stuttering behavior because people who stutter try to conceal their stuttering as to not experience negative listener reaction, negative stigma, shame/embarrassment, frustration, etc. The thoughts of people who stutter are another aspect of the disorder: "I can't take that job because I stutter; I can't ask a question in class because people will look at me funny". The emotional and "cognitive" (thought processes) aspects of stuttering are very treatable. One is not doomed to a life of "mental gymnastics"!

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Ringwood, N.J.: Are children with apraxia more likely to stutter? Thank you.

Vivian Sisskin: Many of the symptoms of apraxia can mimic stuttering. As one searches for articulatory positions, and effortfully tries to sequence sounds, disfluency can result. This is not necessarily the same problem as Developmental Stuttering, which we are talking about today.

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Guilderland, N.Y.: Vivian,

Our 16-year-old daughter (who is academically quite advanced) started stuttering around the sixth grade. Despite weekly speech therapy there seems to be little improvement. Stuttering obviously only adds to all the other difficulties of adolescence -- while the "I'll do what I want!" mindset of the teenager means that getting her to follow her therapist's instructions can be difficult at best. Any suggestions?

Vivian Sisskin: I find group therapy for adolescents to be very powerful. There is nothing like peer support. Some teens have never met another person who stutters. They share stories about their speech successes (and failures, encourage each other, offer advice, and cheer each other on in taking on challenges in their daily lives. The teens are amazing, they make me laugh and they make me cry, and they make me most of all so proud of what they can accomplish!

By the way, I also prefer group treatment for adults as well.

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Arlington, Va. : I have 9-year old Boy/Girl twins. My son has recently been diagnosed with a disfluency disorder. Rather than repeating words he tends to elongate the first syllable of a word, especially at the beginning of a sentence. Ex: "I waaaant to go to the park".

This hasn't been an easy diagnosis because he often times does not exhibit any disfluency. His symptoms tend to be sporadic. Is this common with disfluency? My husband and I have noticed his disfluency is more pronounced when he's tired or very excited about something.

We have just started to work with a speech therapist thru the school system. Can you please explain what "blocking" means? We noticed that sometimes our son will get a slick tic or strange facial expression because he's trying so hard to get out a word or maybe just not to be disfluent. Our school speech path suggested that he try to push thru the words even if he will be disfluent .is that a good approach? Also she suggested that he try to put the "H" sound in front of some words as well. Not sure if this is what airflow therapy is? Any info you can supply would be most helpful. Thank you.

Vivian Sisskin: Some of this terminology can be confusing. A block is when there is interruption or a stoppage, in the sound production, often on the first sound, but sometimes mid-word. To the person who stutters, it feels like the word is stuck. The listener hears silence and often sees struggle. What you describe appears to be a prolongation in the middle of the word (on the vowel), we often refer to these symptoms as dysrhythmic phonation. They are typical of stuttered speech.

Stuttering tends to come and go. It is cyclical. In the preschool years, there are often long periods of what appears to be recovery. Many older children tell me that they had periods when they did not stutter at all, "I didn't stutter in high school, but when I got to college, it started again". This is the nature of the beast, but also gives false hopes in terms of recovery and disappointment when symptoms reappear.

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River Vale, N.J.: What is the difference between stuttering and disfluency? My son started stuttering at around 3 years old. It has come and gone during the past year but now seems to be getting worse. Do you recommend therapy? Also, is there any relationship between stuttering and illness? My son has had several ear and sinus infections. Thank you.

Vivian Sisskin: I like to distinguish between a stuttering disorder and disfluent speech (repetitions, pauses, reformulations, prolongations) that may or may not indicate a disorder of stuttering. Many preschool children pass through a period of disfluency when they are learning complex language, and it is not necessarily stuttering. A speech language pathologist can differentiate these two conditions, although there are times when the lines are blurred. I do notice that many of my clients have worsening of symptoms when they are ill, tired, excited, or the content of the talk is complex/lengthy or emotional. This is probably true of all of us... I know that I am more disfluent during my lectures when I am tired or sick.

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Fairfax, Va.: Can you please explain what is meant by "emotional reactivity?"  Can you give examples of such behavior?

My 3 yo has mild prolongation from time to time, and her therapist has suggested it may be more evident in times of stress. Is this the same thing?

Vivian Sisskin: Emotional reactivity, according to the Vanderbilt study, refers to the tendency to experience frequent and intense emotional arousal .It includes the ease at which the child becomes emotionally aroused as well as the intensity .They also noted that the child who stutters might become more aware or concerned and be less able to regulate the emotions.

The study will be out soon in the Journal of Communication Disorders.

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Vivian Sisskin: Well... I think my fingers need a break, although there are so many more great questions to respond to. I am sorry that I was not able to respond to them all. Thank you all for your interest in this important topic. If you would like additional information, please see some of the Web sites that I mentioned throughout the discussion.

Thanks!

Vivian

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