01

Feb

Speech Therapy Adult Services Part 2 of 2

Continued from Part 1 of Our Series on Adult Services

Stuttering

What it is.

Talking to people can be hard if you stutter. You may get stuck on certain words or sounds. You may feel tense or uncomfortable. You might change words to avoid stuttering. Stuttering is a communication disorder in which the flow of speech is broken by repetitions (li-li-like this), prolongations (lllllike this), or abnormal stoppages (no sound) of sounds and syllables. There may also be unusual facial and body movements associated with the effort to speak. Stuttering is also referred to as stammering. As ASHA Explains:

"We all have times when we do not speak smoothly. We may add "uh" or "you know" to what we say. Or, we may say a sound or word more than once. These are called disfluencies."

People who stutter may have more disfluencies and different types of disfluencies. They may repeat parts of words (repetitions), stretch a sound out for a long time (prolongations), or have a hard time getting a word out (blocks). Stuttering is more than just disfluencies. Stuttering also may include tension and negative feelings about talking. It may get in the way of how you talk to others. You may want to hide your stuttering. So, you may avoid certain words or situations. For example, you may not want to talk on the phone if that makes you stutter more. Stuttering can change from day to day. You may have times when you are fluent and times when you stutter more. Stress or excitement can lead to more stuttering.

Stuttering - How Common is it?

More than 70 million people worldwide stutter, which is about 1% of the population. In the United States, that's over 3 million Americans who stutter. Stuttering affects four times as many males as females. Source

Stuttering - What are the Causes?

There is no one cause of stuttering. Possible causes include the following:

Family history. Many people who stutter have a family member who also stutters.
Brain differences. People who stutter may have small differences in the way their brain works during speech.

You cannot always know which children will continue to stutter, but the following factors may place them at risk:

Gender. Boys are more likely to continue stuttering than girls. Data are currently limited to individuals who identify as male or female.
Age when stuttering began. Children who start stuttering at age 3½ or later are more likely to continue stuttering.
Family recovery patterns. Children with family members who continued to stutter are also more likely to continue.

Stuttering - What are the Symptoms?

The following typical disfluencies happen to many of us and are not stuttering:

Adding a sound or word, called an interjection – "I um need to go home."
Repeating whole words – "Well well, I don’t agree with you."
Repeating phrases – "He is–he is 4 years old."
Changing the words in a sentence, called revision – "I had–I lost my tooth."
Not finishing a thought – "His name is . . . I can't remember."

The following types of disfluencies happen when someone stutters:

Part-word repetitions – "I w-w-w-want a drink."
One-syllable word repetitions – "Go-go-go away."
Prolonged sounds – "Ssssssssam is nice."
Blocks or stops – "I want a (pause) cookie."

You may also notice other behaviors like head nodding or eye blinking. Sometimes people who stutter use these behaviors to stop or keep from stuttering. They may also avoid using certain words or use different words to keep from stuttering. Feelings and attitudes can affect stuttering. For example, frustration or tension can cause more disfluencies. Being excited or feeling rushed can also increase disfluencies. A person who stutters may also stutter more if others tease them or bring attention to their speech. Stuttering may cause a person to be embarrassed and make them feel nervous about talking.

Stuttering - What Does Treatment Look Like?

There are different ways to help with stuttering. Treatment will depend on one or more of the following:

Frequency of stuttering
Reaction when stuttering
How stuttering impacts your everyday life
How others react to your stuttering

For older children and adults, treatment focuses on managing stuttering. An SLP will help them feel less tense and speak more freely in school, at work, and in different social settings. The SLP will also help the person face speaking situations that make them fearful or anxious. This might include speaking on the phone or ordering food at a restaurant. Some adults who started stuttering as a child may want to see an SLP every once in a while. The SLP will talk to the person about how stuttering affects their everyday life and can help the person practice ways to manage stuttering. Children and adults who stutter may want to look into local support groups, where they can talk with others who stutter and learn about other helpful resources.

Stuttering - How does Treatment Improve Quality of Life?

One of the main consequences of stuttering is the false impressions and stigma associated with the disorder. When one is able to eliminate the rate of frequency of their stuttering, they are also able to eliminate these false ideas, such as:

People stutter because they are nervous
People stutter because they are shy
Stuttering is a psychological disorder
Stuttering is caused by bad parenting

Stuttering - Resources

Voice Disorders

What is it? **All content below quoted from the American Speech Language and Hearing Association (ASHA).** A voice disorder occurs when voice quality, pitch, and loudness differ or are inappropriate for an individual's age, gender, cultural background, or geographic location (Aronson & Bless, 2009; Boone, McFarlane, Von Berg, & Zraik, 2010; Lee, Stemple, Glaze, & Kelchner, 2004). A voice disorder is present when an individual expresses concern about having an abnormal voice that does not meet daily needs—even if others do not perceive it as different or deviant (American Speech-Language-Hearing Association [ASHA], 1993; Colton & Casper, 1996; Stemple, Glaze, & Klaben, 2010; Verdolini & Ramig, 2001). A number of different systems are used for classifying voice disorders. ASHA classifies voice disorders as follows:

Organic — voice disorders that are physiological in nature and result from alterations in respiratory, laryngeal, or vocal tract mechanisms
- Structural — organic voice disorders that result from physical changes in the voice mechanism (e.g., alterations in vocal fold tissues such as edema or vocal nodules; structural changes in the larynx due to aging)
- Neurogenic — organic voice disorders that result from problems with the central or peripheral nervous system innervation to the larynx that affect functioning of the vocal mechanism (e.g., vocal tremor, spasmodic dysphonia, or paralysis of vocal folds)
Functional — voice disorders that result from improper or inefficient use of the vocal mechanism when the physical structure is normal (e.g., vocal fatigue; muscle tension dysphonia or aphonia; diplophonia; ventricular phonation)

Learn more about specific voice disorders here:

Voice Disorders - How Common are they?

Voice disorders have been estimated to be present in between 3% and 9% of the U.S. population (Ramig & Verdolini, 1998; Roy, Merrill, Gray, & Smith, 2005). However, information from a large U.S. claims database (Cohen, Kim, Roy, Asche, & Courey, 2012) indicates the point prevalence (i.e., the number of individuals with the condition in the database at the time that data were retrieved) of voice disorders is 0.98% in a treatment-seeking population. This likely suggests that a large number of those individuals with voice disorders do not seek treatment. The prevalence of voice disorders among treatment-seeking individuals has been shown to be affected by gender, age, and occupation: Gender

Prevalence is higher in adult females than in adult males, with a reported ratio of 1.5:1.0
In children, voice disorders are significantly more prevalent in males than in females

Age

Prevalence has been reported to be higher in elderly adults, with estimates ranging from 4.8% to 29.1% in population-based studies
In the pediatric population, the reported prevalence of a voice disorder has ranged from 1.4% to 6.0%

Occupation

Occupational groups that appear to be most at risk for developing a voice disorder include teachers, manufacturing/factory workers, salespersons, and singers
- The estimated prevalence of reporting a current voice problem was higher in teachers (11.0%) than in nonteachers
- Reported prevalence for teachers at a single point in time ranged from 9% to 37%
- Reported lifetime prevalence (i.e., the percentage of teachers who experienced a voice disorder at some point in their lifetime) was between 50% and 80%

Voice Disorders - What are the Causes?

A disturbance in one of the three subsystems of voice production (i.e., respiratory, laryngeal, and subglottal vocal tract) or in the physiological balance among the systems may lead to a voice disturbance. Disruptions can be due to organic, functional, and/or psychogenic causes.

Organic causes include the following:

Structural
- Vocal fold abnormalities (e.g., vocal nodules, edema, glottal stenosis, recurrent respiratory papilloma, sarcopenia [muscle atrophy associated with aging])
- Inflammation of the larynx (e.g., arthritis of the cricoarytenoid or cricothyroid, laryngitis, laryngopharyngeal reflux)
- Trauma to the larynx (e.g., from intubation, chemical exposure, or external trauma)
Neurologic
- Recurrent laryngeal nerve paralysis
- Adductor/abductor spasmodic dysphonia
- Parkinson's disease
- Multiple sclerosis

Functional causes include the following:

Phonotrauma (e.g., yelling, screaming, excessive throat-clearing)
Muscle tension dysphonia
Ventricular phonation
Vocal fatigue (e.g., due to effort or overuse)

Psychogenic causes include the following:

Chronic stress disorders
Anxiety
Depression
Conversion reaction (e.g., conversion aphonia and dysphonia)

Recognizing associations among these factors, along with patient history, may help in identifying the possible causes of the voice disorder. Even when an obvious cause is identified and treated, the voice problem may persist. For example, an upper respiratory infection could be the cause of the dysphonia, but poor or inefficient compensatory techniques may cause dysphonia to persist, even when the infection has been successfully treated.

Voice Disorders - What are the Symptoms?

The generic term dysphonia encompasses the auditory-perceptual symptoms of voice disorders. Dysphonia is characterized by altered vocal quality, pitch, loudness, or vocal effort. Signs and symptoms of dysphonia include

roughness (perception of aberrant vocal fold vibration);
breathiness (perception of audible air escape in the sound signal or bursts of breathiness);
strained quality (perception of increased effort; tense or harsh as if talking and lifting at the same time);
strangled quality (as if talking with breath held);
abnormal pitch (too high, too low, pitch breaks, decreased pitch range);
abnormal loudness/volume (too high, too low, decreased range, unsteady volume);
abnormal resonance (hypernasal, hyponasal, cul de sac resonance);
aphonia (loss of voice);
phonation breaks;
asthenia (weak voice);
gurgly/wet sounding voice;
hoarse voice (raspy, audible aperiodicity in sound);
pulsed voice (fry register, audible creaks or pulses in sound);
shrill voice (high, piercing sound, as if stifling a scream); and
tremulous voice (shaky voice; rhythmic pitch and loudness undulations).

Other signs and symptoms include

increased vocal effort associated with speaking;
decreased vocal endurance or onset of fatigue with prolonged voice use;
variable vocal quality throughout the day or during speaking;
running out of breath quickly;
frequent coughing or throat clearing (may worsen with increased voice use); and
excessive throat or laryngeal tension/pain/tenderness.

Signs and symptoms can occur in isolation or in combination. As treatment progresses, some may dissipate, and others may emerge as compensatory strategies are eliminated. Auditory-perceptual quality of voice in individuals with voice disorders can vary depending on the type and severity of disorder, the size and site of lesion (if present), and the individual's compensatory responses. The severity of the voice disorder cannot always be determined by auditory-perceptual voice quality alone.

Voice Disorders - What Does Treatment Look Like?

Treatment Approaches Norms within different settings are considered when determining vocal needs and establishing goals. For example, vocal norms and needs within the workplace may be different from those within the community (e.g., home and social settings). SLPs often incorporate aspects of more than one therapeutic approach in developing a treatment plan. Approaches can be direct or indirect.

Direct approaches focus on manipulating the voice-producing mechanisms (e.g., phonation, respiration, and musculoskeletal function) in order to modify vocal behaviors and establishing healthy voice production (Colton & Casper, 1996; Stemple, 2000).
Indirect approaches modify the cognitive, behavioral, psychological, and physical environments in which voicing occurs (Roy, et al., 2001; Thomas & Stemple, 2007). Indirect approaches include the following two components:
- Patient education—discussing normal physiology of voice production and the impact of voice disorders on function; providing information about the impact of vocal misuse and strategies for maintaining vocal health (vocal hygiene)
- Counseling—identifying and implementing strategies such as stress management to modify psychosocial factors that negatively affect vocal health (Van Stan, Roy, Awan, Stemple, & Hillman, 2015)

A therapeutic plan typically involves the use of at least one of the direct approaches and one or more of the indirect approaches based on the patient's condition and goals. Some clinicians concentrate on directly modifying the specific symptoms of the inappropriate voice, whereas others take a more holistic approach, with the goal of balancing the physiologic subsystems of voice production—respiration, phonation, and resonance. Many clinicians begin by

identifying behaviors that are contributing to the voice problems, including unhealthy vocal hygiene practices (e.g., shouting, talking loudly over noise, coughing, throat clearing, and poor hydration) and
implementing healthy vocal hygiene practices (e.g., drinking plenty of water and talking at a moderate volume) and practices to reduce vocally traumatic behaviors (e.g., voice conservation).

Voice Disorders - Resources:

See ASHA information for professionals on the Practice Portal’s Voice Disorders page.