FLUENCY DISORDERS.pdf /KUNNAMPALLIL GEJO

7/27/2019 FLUENCY DISORDERS.pdf /KUNNAMPALLIL GEJO

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FLUENCY DISORDERS

KUNNAMPALLIL GEJO JOHN,

MASLP

KUNNAMPALLIL GEJO JOHN


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Definition :

Fluency & Disfluency

Factors affecting fluency

Dimensions of fluent speech

Theoretical constructs in fluencydevelopment



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FLUENCY

DEFINITION:

Fluency refers to the effortless production of longcontinuous utterance at a rapid rate, be it the first orsecond language.

- Stark Weather (1980)

Stark Weather (1987) considered fluency as amultidimensional behavior and the dimension of fluencyare:

- continuity or smoothness of speech

- rate of speech

-effort a speaker makes in producing speech (StarkWeather 1981)

-rhythmic structures (Stark Weather 1981)



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According to Perkins (1977),

FLUENCY is a barometer for the entire

speech system, with its limits apparently set by

adequacy or performance of the other

dimensions of speech.

According to Kunnampallil Gejo (2009),

Fluency refers to the uninterrupted productionof long continuous smooth utterance at a minimum

rate of the language which is legible for the speaker

and listener.



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DYSFLUENCY:

The term dys denotes pathology or abnormal .

Dysfluency abnormal instances of fluency

failure, ie ; those most closely associated with

stuttering. Dysfluencies have been broadly defined as

including all instances of broken words

( ie; part-word, syllable, or sound repetitions or

prolongations)

and/or fluency disruptions associated with

excess tension or struggle.



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In contrast, Disfluency has been proposed as

the appropriate term for normal non-disfluencies.

Disfluencies or normal non-fluencies areconsidered to include

- silent

- non tense pauses

- interjections

- revisions

- word or phrase repetitions without

indications of stress or struggle.



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Normal disfluencies have been cataloged byseveral authors, and there is general agreementamong them as to what constitutes disfluency.

Eight commonly used categories of disfluencyare:

* part-word repetition

* single-syllable word repetition* multisyllabic word repetition

* phrase repetition

* interjection

* revision- incomplete phrase

* prolongation

* tense pause



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Some of the major distinguishing features

that differentiate normal disfluency fromstuttering are

# the amount of disfluency

# the number of units of repetitions &interjections

# type of disfluency, especially in

relation to the age of the child.



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Johnson (1961) classified the followingtypes of speech behavior as disfluencies:

1. Interjection2. Part-word repetition

3. Word repetition

4. Phrase repetition5. Revisions

6. Incomplete phrases

7. Broken words8. Prolonged sounds



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1. Interjection of sounds, syllables, words or phrases:

This implies extraneous sounds uh, erhmm;

- extraneous words such as well which are distinct,from sounds and words associated with the fluent textor with phonemes included one or more units orrepetition of the interjected material;

For eg: uh-uh-uh are each counted as one instance ofinterjection .

The number of times the interjection is repeated withineach instance is also noted, uh-uh is an example ofan interjection; repeated once and uh-uh-uh is an

example of an interjection repeated twice.



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2. Part- word repetition:

This category has repetitions of parts of words-

that is syllables and sounds. Within each instance of repetition the number of

times the sound or syllable is repeated is

counted; box-buy involves one unit of repetition

and guh-guh involves two units.

This does not distinguish between sound and

syllable repetitions.

eg: ruh-ruh-ruh cuhcome, ba-ba-baby & a-bou -bout



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3. Word repetition:

This category includes repetitions of

whole words including words of one syllable. Both the number of instances and number of

repetition units within each instance are

counted. I-I-I, was- was & going are samples

of instances of word repetition; the first involves

two units of repetition and each of other two

involves two unit.

A word repeated for emphasis as in very, veryclear is not counted as a disfluency.



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4. Phrase repetitions:

This category includes repetitions of two or more

words.eg: I was I was going

5.Revisions : Instances of revision include those in which the

context of a phrase is modified, or in which there

is a grammatical modification. Change in

pronounciation of a word is also counted as arevision.

eg: I was- I am going



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6. Incomplete phrases :

- one which in the thought or context is notcompleted and

- which is not an instance of phrase repetition.eg: she was- and after she got there he come.

7. Broken words :

- Words which are not completelypronounced and which are not associated with anyother category, or

- in which the normal rhythm of the word isbroken in a way that definitely interferes with thesmooth flow of speech are characterized by thiscategory.

eg: I was g-(pause)- going home.



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8. Prolonged sounds :

This category includes sounds

judged to be unduly prolonged. If a sound is prolonged twice, it is

counted both as a prolonged sound

and a part- word repetition.



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FACTORS AFFECTING FLUENCY

Several factors

- continuity

- rate

- effort

- rhythm- physiological framework of fluency

- motor and linguistic factors

- language complexity

- grammatical categories- sexs

- situation and

- environmental factors seems to affect fluency.



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1. CONTINUITY:

Pauses whether filled or unfilled are acommon feature of speech. We pause on the

average every 4.8 words and our perception ofspeech seems to be more continuous than thereality of it. Presumably, this happens becausewe focus on the content of communication we

listen to the ideas and not contribute to theseideas is filtered out by our perceptualmechanism. This is not to say that pausesnear convey information, but the information

sometimes they convey has to do with theprocess of communication or with the speakerslevel of uncertainty rarely with the content(Stark Weather 1987).



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There has been a presumption from the earliest

days of research in this area, that the pauses

were occasions on which language was being

formulated and although it seems likely that this

is true for some pauses it may not be true for all

pauses.

In support of the idea that the two types ofpauses are different in kind, Clark notes that

idiosyncratic pauses convey no information, and

tend to be overlooked and concludes that

conventional pauses are information bearingelements of sentences.



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2. RATE OF SPEECH:

This is the rate in which continuous syllablescan be produced as a function of speed of

articulatory movement and the degree of co-articulatory overlap.

( Gay,1978; Stark Weather, 1981).

Females produce utterance that are more

variable in rate and longer utterances and theyare more fluent than males ( Malecot, Johnsonand Kizzias, 1972).

Rate depends on the type of syllables produced,

CCV and CVC syllables are produced at a fasterrate than VCC syllables.



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3. EFFORT:

Speech being produced effortlessly, is a

characteristic of fluent speech ( Stark

Weather,1987).

The two types of efforts are :

- mental effort or concentration where the

thoughts are focused on the content rather thanon the processes of utterances and

- muscular effort, where the effort

provides a flow of air, opens and closes theglottis and moves the tongue, lips, jaw, velum

and pharynx(Stark Weather,1987).



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Among the speech sounds, stops &

fricatives require more effort than nasalsand glides.

(Malecot,1955; Worth & Sakuda,1966).

Effort is consequently related torate, stress & duration of speech sounds.

Effort of mind & effort of muscle are both

aspects of fluency. It is difficult to measurethe former.



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4. RHYTHM:

Rather than being a dimension of fluency,

rhythm seems to promote or enhancefluency.

Speech rhythm serves fluency by makingit easier for us to talk faster.

It does this in several ways- unstressedsyllables are shorter and thus require lesstime.

Martin(1972) says that rhythmic patterningcarries a heavy information load inordinary connected speech



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5. PHYSIOLOGICAL FACTORS:

Dejoy & Gregory (1985) indicated that during the laterpreschool years, children become more accomplished in

the symbolic/ motoric selection. They added that the forward flow of speech becomesrelatively more automatic

The reduction in frequency may well reflect increasedtemporal precision and control and simplification of the

control process (Sharkey & Polkins, 1985). Van riper (1971) indicated that disruption of proper

programming of the physiological movements necessaryfor fluent speech causes stuttering.

Spatial & timing co-ordination are essential physiologicalaspects of fluency (Stark Weather,1987).



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6. MOTOR FACTORS:

Muscles that contract during a speech willreceive a high frequency neural impulses at the

proper movement. Muscles which are relaxed will receive a low

frequency neural impulse.

The capacity to relax antagonist muscles hasmore to do with frequency than the capacity tocontract agonist muscles, which is proved instutters (Freeman & Ushijima,1978).

Along with the mass and stiffness of theperipheral mechanism, certain neuralmechanisms also have an important influenceon the timing of movements.



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7. LANGUAGE MATURITY:

It is one of the important factor which is

related to fluency. Increased ability in phonology, semantics,

syntax & pragmatic knowledge influence

fluency. As these abilities grow, sentences become

longer and more complex.



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8. LANGUAGE COMPLEXITY:

Analysis of language samples of Haynes &

Hood (1978) who studied 20 males & 20female children between 5 to 6yrs

supported that language influences

dysfluency especially in the complexmodeling condition.

Significant increase in word repetition,

revision, incomplete phrase and

dysrhythmic phonations occurred in the

complex modeling situation.



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9. GRAMMATICAL CATEGORY:

It is found that the frequency of occurrence ofboth unfilled & filled pauses is more before

*content words than functionwords (Fagen,1982).

The words following filled pauses are difficult topredict and filled pauses occur mainly before

words which are highly uncertain. Filled pauses are much more common at the*beginning of clauses than within clause(Hawkings,1971) and

- they tend to occur *before longer andmore complex sentences (Smith & Lallijee,1974).



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10. SEX:

Some studies have indicated that males

show greater disfluencies than females inthe age groups 2-6yrs (Haynes &

Hood,1977; Yairi,1981; Wexler &

Mysak,1982).



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11. ENVIRONMENTAL FACTORS:

The person to whom the child is speaking

is also an important factor whichinfluences fluency.

It has been found that the child speaks

more fluently with a puppet than with anexperimenter.



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DIMENSIONS OF FLUENCY

There are several dimensions of fluency.

Stark weather (1987) defines speech fluency in terms ofcont inui ty, durat ion, co-art iculation & effor t.

1) Continuity :

- refers to the degree to which syllables & wordsare logically sequenced as well as the presence or

absence of pauses. If the semantic units follow one another in a continual

flow of information, the speech is interpreted as fluent.



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If however, the units of speech fail to flow

in a logical sequence, information does notflow.

Despite a continual flow of sound & the

absence of pauses, the speech is notthought of as fluent.



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Another aspect of continuitypauses

The pauses in the sequence of speech can be

viewed from several perspectives. Clark (1971) differentiates pauses as

conventional & idiosyncratic.

Conventional pauses are used by speakers to

signal a linguistically important event.

Idiosyncratic pauses reflect hesitation or

uncertainty on the part of the speaker. These

pauses indicate a decision- making processconcerning upcoming word, choice, style or

syntax.



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Pauses also have been considered as

unfilled or filled.

Unfi l led pausesare characterized by asilence lasting longer than ~250millisec

(Goldman-Eisler,1958).

This duration is suggested as a convenientthreshold for normal silent intervals during

fluent speech, since normal word junctures

rarely exceed this duration ( eg: thejuncture necessary to distinguish night rate

from nitrate).



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Filled pausesare characterized by

essentially meaningless sounds such asah, or, uh & um.

Whether the speech is considered fluent

depends on many other features includingthe frequency of these pauses along with

the occurrence of other aspects of fluency.



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Rate of speech also signals the perception of fluency.

If a speaker is producing a lengthy utterance, the rate ofspeech is likely to be more rapid (Malecot, Johnston &Kizziar, 1972).

Speaker is producing speech at a slow rate, everythingelse being equal, the speaker is not likely to beevaluated as being non-fluent.

Conversely, speaker is producing speech at a very rapid

rate, he or she is not likely to be evaluated as beingproduced.

Although the rate of production is one aspect of fluency,it does not appear to be a primary dimension.

The flow of speech & information is based not only onrate, but on a combination of many factors, particularlythe ease of production.



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2) Duration of speech segments relates

closely to the co-articulation of the

segments. The duration of the consonants & vowels

of a language varies considerably with

speech rate, phonetic & linguistic context.For eg: stressed syllables are longer than

unstressed ones (Umeda, 1975).

Sound segments are longer at theinitiation & termination of syllables, words

& phrases (Fowler,1978).



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Segment durations are dramatically influenced

by

- position in the syllable (initial consonants

are longer than syllable-final consonants),

- length of the word (segments are shorter

with longer words) &- sentence length (segments are shorter

during longer sentences) [Huggins, 1978]

Co- articulatory effects are greater when thespeech rate is increased ( Gay,1978).



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Co-articulatory effects contribute to the

timing & smoothness of speech.

In fluent speech, articulatory movementsbetween the sounds, syllables & words are

done with ease.

The transitions are smooth & there is acontinuous flow of overlapping sounds.



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The final dimension of fluencyEffort.

Starkweather (1987) distinguishes two types of

effort:- effort associated with linguistic planning

- effort associated with muscle movement.

Clinically, it may be that the listeners perceptionof effort, in combination with the other

dimensions of fluent speech production, is the

common indicator of fluent speech.

As Starkweather suggests, Fluent speech iseffortless in two distinct ways : It requires little

thought & it requires little muscular exertion.



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Fluent speech is characterized by little

attention being paid to the process of

production; speaking is automatic. The thought process in fluent speech

takes relatively little time, while the

execution of speech takes somewhatlonger.

Fluent speech is characterized by little

sensation of opposition or constriction ofairflow.



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On the other hand, people who stutter are at the

opposite end of the continuum of effort.

Greater effort is associated with all the following:

- greater contact between articulators

- greater impedance between the flow of air &

the structures of the vocal tract, beginning withthe vocal folds

- greater subglottic air pressure

With the speaker producing speech in thisfashion, it is likely that speech will be judged as

non-fluent.



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DEVELOPMENT OF FLUENCY

Initially, the speech of children lacks

fluency. When demand from the society

increases to produce fluent speech,

fluency increases. It increases withincrease in age. If the child is capable of

meeting the demands of the society , the

speech is fluent. If the child is incapable ofmeeting societal demands, dysfluent

speech is produced.



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1) Development of Speech Continuity:

Continuity is a factor affecting fluency.

Kowal & Sabin(1975) studied 168 normalchildren from KG to 12th grade.

The most common dysfluencies are,

* pauses

* repetitions

* false starts

* parenthetical remarks



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Frequency of dysfluencies did not change

from KG to 12th

grade children. So it wasunderstood that frequency could not be

taken as a tool for assessing fluency.

It was noticed that false starts, repetitions& pauses decreased steadily from KG to

12th grade.

There was a sudden increase in false

starts at 4th grade.



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- It was speculated that, at this age as

children were formally trained in terms of

grammatical knowledge, they might be over

conscious of their speech and would try to

apply their grammatical knowledge. Hence, a

number of false starts would occur.

Parenthetical remarks increased steadily fromKG to 12th standard. This was believed to give

continuity to their speech.

There was no developmental trend seen in

terms of dysfluencies.



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Dejoy & Gregory (1975) studied children

between 3 - 5yrs of age. They reported thatrepetitions of words, phrase, part word,

incomplete phrases & dysrhythmic phonation

were more commonly seen in 3yr old than

5yr old.

Yairi (1981) studied 33 normal children of

24-33mths . He found that part word & small

word repetition are most commonly seen inyoung children.



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Revisions & incomplete phonations did not

show any developmental trend 2-4yrs.

Repetitions, tense phrase, dysrhythmic

phonation decline steadily from 2-4yrs.

Interjections & repetitions of words &

phrases decline steadily with increase in

age.



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2) Development of Rate:

Rapid rate is an aspect for fluency .

Many researchers have studied rate by thefollowing ways,

# measuring duration of pauses

# measuring syllables per second# measuring duration of segment

(length of utterances)

From the studies, it has been reportedthat, there is a clear cut trend indevelopment.



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Duration of pauses:

Kowal & Sabin (1975) reported that

development of rate shows there is adramatic development of fluency.

There is a rapid change in terms of

duration of pauses from KG 2nd gradechildren. They also observed that males

have longer unfilled pauses as compared

to females & duration of pauses decreasewith increase in age.


S ll bl d


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Syllables per second :

Kowal & Sabin (1975) reported that there is a shortincrement in terms of syllables per second from KG 2nd

grade children. It is leveled at 4th grade.

A step increase is seen between 4th & 8th grades.

From 8th grade onwards, not much increase is seen.

Therefore, rate of speech in terms of syllables/sec showsa steady increase in school age children.

Black & Walker (1950) reported an adult speaker is ableto speak at an average of 5-6 syllables/sec.

Armster (1984) reported that, rate of speech show a

clear cut developmental trend in pre-school children.


D ti f S t/Utt


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Duration of Segment/Utterance :

Speaking slowly & precisely is one of the

characters of children speech. The speech of an adult is faster & has

many overlapping co-articulatorymovements.

Studies have shown that, duration ofsegment increase with increase in age.

With increase in age, there is a decrease

in duration of individual sounds, so fluencyof speech increases.



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Duration of /s/ in word initial position is

brief in 7yr old as compared to 5yr oldchildren.

Duration of sound is shorter in longer

utterances/words, unstressed words &sounds in initial position.

Smith (1984) reported that 2-4yrs is the

critical period for duration ofsegment/utterances.



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3) Development of Ease of Speech:

Effortless speech is an influential factor in

maintaining fluency. The effort may be mental or physical:

- the amount of time an individual takes

in planning an utterance reflects in theamount of mental effort required in fluentspeech.

- the amount of time taken in executing

an utterance reflects on the amount ofphysical/muscular effort required for fluentspeech production.


I hild t i l i di ti th t


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In younger children, rate is slower indicating thatthe amount of time spent in executing anutterance is more .therefore, physical effort is

more. In adults, rate of speech is faster because time

spent in executing an utterance is less & so,physical effort is less.

Presence of pauses & repetitions indicates theamount of time spent in planning & therefore,mental effort taken with increase in age, there isa decrease in mental & physical effort.

Co-ordination: articulators & the 3 systems areimportant for production of fluent speech.


R h h h th t DDK t


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Researchers have shown that, DDK rate

increases in age & continues till 18-20yrs.

Fast rate of repetition shows steady increase

from 6-19yrs.

Variability seen in terms of speech production

usually decreases with increase in age.

Researchers have shown that, good speechmotor control capacity like adults is acquired

from 8-12yrs.

They also found that as the nervous systemdevelops till adolescent speech motor

development also takes place till that time.


T i hild h b


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To summarise childrens speech becomesincreasingly fluent as they mature.

As the fluency increases children also learn to

deal with lapses of fluency, such asdiscontinuous in more sophisticated. Thegrowing capacity to talk more is due toincreasing demands for fluent speech, the

demands placed on children by the people theycommunicate with and by themselves.

Most children show increased co-articulatoryundershoot, utterances and useless effort in

talking. Hence, all elements of fluency seems to grow.



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Growth of fluent speech comes from several areas.

There is increasing control over the movements of thevocal tact.

This control develops in several ways.

First, there is growth in the childs ability to react rapidlyto stimuli.

Second, there is an increase in the childs ability toco-ordinate the simultaneous movements of differentparts of the vocal tract.

Third, the ability to plan and then execute a sequence ofmovements.



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Another capacity comes from rhythm.

The sense of rhythm develops and makes it

easier for a child to anticipate the movement of

speech production. one of the growing demands

is the child's development of language skills.

Increased syntactic, semantic, phonologic &pragmatic knowledge contributes to this demand

for fluency.

As the childrens syntax develops, their

sentences become longer & structurally morecomplex.


Because the length of utterance is correlated with the


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Because, the length of utterance is correlated with therate of speech, the children must deal with a demand toincrease the speed with which the vocal tract partsmove.

As the childs knowledge of the rules of phonologyincreases they become interested in using longer words& phrases and more difficult combination of sounds toexpress intentions.

Childs pragmatic knowledge also grows and this also

places a demand on the fluency of speech. The speech of young children is characterized by a

spout of anxiety at 2 or 3yrs of age, their speech is averbalization of their current thought or activity.

With increased maturity speech becomes more

controlled and directed to more specific purposes.Growth in pragmatics seems to diminish the spoutanxiety of childrens speech.


It is not only the rules of language but also the people


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It is not only the rules of language but also the peoplewhom the child communicates place demands on them.

These people include parents, sibling etc.

Children have a tendency to use speech & language thatis similar to that used by those they are talking to- whenparents talk to their children using sophisticatedlanguage, syntactically complex and with an advancedvocabulary, the children try to use the same form.

Some children do not develop the capacity for fluentspeech as rapidly as others, and at times the demand forfluency made by their environments are too much forthem to handle.

When this is the case, fluent speech breaks down..


These frequent episodes as likely to cause the


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These frequent episodes as likely to cause thechildren to try harder- to get words out fasterparticularly words that have been produced

discontinuously to struggle with them, forcingand pushing with increased air pressure and totense the speech musculature so that is stiff,slow moving, un co-ordinated and tremulous.

This is likely to slow the rate at which such

children produce information. During the period of development of speech

behavior, to child learns how to talk semiautomatically.

When the patterns of struggle tension andemotional reaction have become habitual andsemi-automatic stuttering has developed


INDIAN STUDIES RELATED TO


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INDIAN STUDIES RELATED TODEVELOPMENT OF FLUENCY:

Naga Poornima (1990) studied Kannada

speaking normal children between the agerange of 3-4yrs.

Story telling & picture description were used.

Dysfluencies noticed were pauses, repetitions,false starts & parenthetical remarks.

Unfilled pauses, false starts were observedmaximally during picture description. Number ofunfilled pauses decreased between 3-3.8yrs, butsudden increase was seen from 3.8-3.10yrsafter which there was a decline between 3.10-4yrs. No developmental trends were observed.



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Repetitions increased from 3-3.4yrs but

decreased from 3.6-4yrs.

False starts were seen more in the picturedescription tests in the word initial position.

Parenthetical remarks were seen more in

story-telling tasks. Frequency increasedfrom 3-3.4yrs, decreased from 3.4-3.8yrs

and again increased from 3.8-4yrs.



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Indu (1990) :

Studied Kannada speaking children

between 4-5yrs of age.

Connected speech was used.

Pauses, repetitions & parenthetical

remarks were most commonly seen in

content words than in function words.

They were seen more in the initial position


Yamini (1990) :


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Yamini (1990) :

Studied Kannada speaking normal children of 5-6yrs.

She used 6 sets of picture cartoons Common dysfluencies observed are :

# filled & unfilled pauses

# audible inspirations

# parenthetical remarks# false starts

# repetitions

These dysfluencies occurred more before nounsthan other grammatical categories and isobserved more in initial position.



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Rajendraswamy (1991):

Studied Kannada speaking normal children

between the age range 6-7yrs. 6 sets of panchatantra stories were used.

He found that increase in % age of dysfluency

was present from 6-6.6yrs.

Common dysfluencies observed were :

* filled pauses

* false starts

* repetitions

* parenthetical remarks


Less common dysfluencies were :


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Less common dysfluencies were :

* audible inspirations

* broken words* unfilled pauses

More dysfluencies seen on/ before nouns,

verbs, conjunctions & interjections.

Less commonly seen on/before

prepositions & adverbs.

Dysfluencies were reported to be mainly ininitial position.


Sharma (1991)


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Sharma (1991) :

Studied dysfluencies in Hindi speaking normal children

between 6-7yrs.

Percentage of dysfluencies decreased from 6-6.4yrs.

Maximally occurring dysfluency was unfilled

Filled pauses were seen maximally between 6.6-6.8yrs.

Parenthetical remarks were seen between 6.6-6.8yrs Prolongations were less commonly seen.

No definite pattern was seen in the occurrence of

dysfluencies.

Dysfluencies were present mainly in the initial position.


DEVELOPMENT OF


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DEVELOPMENT OF

DYSFLUENCY

Froeschels (1921) depicted the

development of stuttering as a process in

which simple repetitions by progressive

stages became more rapid, irregular,forced, and finally inhibited under the

pressure of some penalty.

Bluemel (1932) termed the incipient stageof the disorder primary stuttering.



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He noted that it often consisted of the repetition

of the first word or syllable of the sentence and

that it frequently had a tendency to disappear

and return repeatedly over a period of months or

years.

He described secondary stuttering ascharacterized by the childs consciousness of

the impediment, physical effort, the use of

starters, synonyms and other attempts to control

or conceal stuttering, anticipation, above all fear of letters, words, people & speech situations.



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Van Ripers Four Tracks :

Van Riper (1982) offered a descriptive

scheme which placed particular stress on

the variability of stuttering


T k 1


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Track 1

- Van Riper found the symptoms to consist

initially of effortless, unhurried repetitions ofsyllables & words, marked by extreme

fluctuations & long remissions.

- Onset was gradual.

- As the disorder progressed the repetitions

became more rapid & irregular, & there

appeared in sequence prolongations, tension &

forcing with intermittent evidence of concern onthe part of the child, associated movements,

word & situation fears & avoidance.



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Track 2

Children who were late in beginning to talk,

the stuttering was said to take the form of rapid,irregular syllable & word repetition from thebeginning.

Later, silent intervals, revisions, &

interjections appeared, & the pattern took onmany aspects of cluttering.

Thereafter the pattern changed relativelylittle.

Word & sound fears were generally mild &tended to develop late.


Track 3


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Track 3

Sudden inability to speak, or complete

blockage.

Very soon this was followed by severe

forcing & struggle, breathing abnormalities,

signs of frustration, associated facial & other

tensions, fear & avoidance.In most cases the severe struggle reactions

abated after a while & followed first by

prolongation & then by syllable repetition.



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Track 4

Children who were reported to have

begun to stutter rather suddenly with

repetition of phrases, words, & later

syllables.

They tended to stutter openly withfew avoidances & showed little changes in

their stuttering over the years.



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