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UNDERSTANDING AND
MANAGING FLUENCY DISORDERS
2 Typical disfluency 15
CHANCHAL CHAUDHARY
5 Assessment of stuttering 91
AMUDHU SANKAR, ANJANA B. RAM, PALLAVI KELKAR
AND SANTOSH MARUTHY
9 Cluttering 186
PALLAVI KELKAR
References211
Appendix A Detailed information gathering 250
Appendix B Impact Scale for Assessment of Cluttering and Stuttering
(ISACS)254
Index265
Contributors
It gives us immense pleasure and satisfaction to finally be able to put out a go-to
book for students and practitioners interested in fluency disorders. Understanding and
Managing Fluency Disorders is an amalgamation of the experience, expertise and hard
work of many academicians, all of them from different parts of India.
For the uninitiated, India is a country synonymous with diversity. Diversity in
terms of geographical landscape, languages, religions and cultures is inseparable from
the Indian sociocultural fabric. In the present day and age, as technology and accessi-
bility makes the world shrink, students across the globe must keep themselves abreast
of how different facets of a disorder vary across countries and cultures. Putting out a
book from India to the rest of the world, then, was something we foresaw as a neces-
sity for broadening readers’ perspectives on fluency and its disorders.
You will find in this book, numerous examples of this diversity through examples
and case vignettes. The case vignettes will also reflect two other features prominently
seen among the Indian population. Firstly, the fact that bilingualism or multilingual-
ism is a rule rather than an exception. Secondly, the culture here is predominantly
collectivistic or group oriented. While collectivism, on one hand, brings with it
strong family support, on the other hand, it also adds to barriers faced by patients in
the form of societal pressure to conform or blend in.
Speaking of barriers, another salient feature of this book is the inclusion of an
ICF perspective. All the authors of this book have found assessment, intervention
and documentation along the lines of the ICF to be extremely useful. This, in our
opinion, would aid beginning clinicians of fluency in understanding the multifacto-
rial mosaic that is a fluency disorder. It would help them look at the people behind
the disfluencies.
This last task is, in fact, practically very feasible for students in India. With a pop-
ulation which is the second largest in the world, students get abundant exposure to
the entire continuum of fluency to disfluency. However, the sheer numbers of cases
seen on a daily basis make systematic documentation a difficult task. This comes in
the way of gaining a broader insight into the people they see through assessment.
To increase the ease and time efficiency of record keeping, therefore, we bring to
the readers a detailed protocol for documenting assessment-related information. We
have also included a complete impact assessment tool, the ISACS, which is the only
x Foreword
tool that can assess impact of stuttering and/or cluttering from two perspectives –
that of the person with disfluencies and that of their significant other. It has the
added advantage of an indigenous normative, so culture specific impact assessment
is finally possible. The systematic record-keeping protocol as well as the ISACS can
be found in the Appendices.
We would like to take this opportunity to thank the publishers for giving wings
to our ideas and our respective institutes for encouraging us in this endeavour. We
thank all the contributing authors for giving us their time, efforts and cooperation
in putting this book together. We extend our heartfelt gratitude to those who gave
prompt and valuable feedback when we consulted them about some aspect of the
book. Most importantly, we can’t but thank all the people who visited our clinics
and took us a step closer to understanding fluency better. Finally, a special thank
you to our parents, in-laws, spouses and above all, our kids, for that little nudge
of motivation when meeting deadlines seemed impossible, for their patience and
understanding when we spent long hours poring over the manuscript and for smiles
at the end of long days that energized us to keep going till the end!
We hope that our efforts translate to positive educational outcomes for students
of fluency and consequently for persons with fluency disorders.
Introduction
Speech is produced with simultaneous and successive programming of muscular
movements. The different dimensions of speech include voice, articulation, fluency
and prosody. This chapter mainly aims to define and elaborate on the concept of flu-
ency, different components of speech fluency and prosody. Development of fluency
and factors affecting it are also discussed.
What is fluency?
The word “fluency” is derived from Latin word fluere, which means “to flow”.
Based on this root word, anything that involves a smooth flow can be considered
as fluent. In the domain of language, fluency may be interchangeably used with
proficiency. A person is considered as fluent if he or she is able to speak either the
first language (L1) or the second language (L2) rapidly and continuously without
any difficulty. Fluency in the written modality could be defined as being able to
read or write in a particular language in a smooth, uninterrupted manner. In order
to be fluent in a language, then, an individual must gain fluency in each linguistic
component; in other words, syntactic fluency, semantic fluency, phonologic fluency
and pragmatic fluency. A person is thought to be phonologically fluent if they are able
to construct long and complicated strings of phonological sequences without any
difficulty; syntactically fluent if they are able construct highly complex sentences;
semantically fluent if they possess an ability to access a large vocabulary; and pragmati-
cally fluent if they are skilled at speaking at a variety of speaking situations.
Dimensions of fluency
In speech communication, fluency may be defined as effortless continuous speech
uttered at a rapid rate (Starkweather, 1987). This definition highlights that fluent
speech needs to be uttered continuously, at a rapid rate with a minimal amount of
effort. Hence, fluency is a multidimensional behaviour, its domains being continu-
ity, rate and effort. Starkweather (1987) also added speech rhythm as the fourth
domain. Each of these dimensions of fluency are discussed briefly below.
DOI: 10.4324/9781003367673-1
2 Santosh Maruthy
Continuity
Continuity refers to smooth flow of speech. It reflects how speech flows from one
sound to another in a word, from one word to another in a phrase and from one
phrase to another in a sentence. Although ideally fluent speech needs to be devoid
of any interruptions, conversational or spontaneous speech is sometimes interrupted
by different sets of behaviours, which may break the smooth flow of speech. One
kind of speech interruptions that are seen in typically speaking individuals are called
as disfluencies. Examples of these behaviours are pauses (filled and unfilled), revi-
sions, parenthetical remarks, multisyllabic word repetitions, etc. The second type of
speech interruptions that are majorly seen in individuals who have fluency disorders
are referred to in many textbooks as dysfluencies. These refer to abnormal motoric
breakdowns in speech. For example, repeating a sound or syllable multiple times,
prolonging a sound (voiced or voiceless) or uttering a broken word. Individuals with
fluency disorders may have disfluencies, that is, the stoppages that are usually seen in
typical speakers, along with dysfluencies. Some textbooks, on the other hand, use
the word “disfluencies” to refer to stoppages of any kind. We would be using the
uniform term “disfluencies” in the present text. Further classification of these disflu-
encies into typical and atypical ones will be discussed in Chapters 2 and 3. A detailed
account of different types of disfluencies which are characteristic of typically speak-
ing individuals and persons with fluency disorders is given below.
Pauses
clauses (Boomer, 1970). Frequency and duration of pauses can be documented for
both filled and unfilled pauses.
Repetitions
Like pauses, repetitions also interrupt the continuity and forward flow of fluent
speech. As its name implies, a repetition involves repeated production of an utter-
ance. A person might repeat a sound, syllable, word or phrase. For example, “p p
pen” would be sound repetition, “ca ca camp”, a syllable repetition, “ball ball ball”,
a word repetition, and “I want I want I want coffee”, a phrase repetition. Sound
and syllable repetitions can be combined under the blanket term “part-word repeti-
tions”. Word repetitions can involve monosyllabic words, such as “I I I want cof-
fee” or multisyllabic words, such as “Mohan Mohan Mohan, can you come here?”
Frequency of repetitions in speech can be calculated in terms of a percentage. This
is done by counting all the repeated syllables/words, dividing the number by the
total number of syllables/words and then multiplying the resultant number by 100.
For instance, if there are 25 part-word repetitions in a total of 300 words, then
(25/300)∗100 = 8.33%. Some researchers also note the total number of repeated
units (Ambrose & Yairi, 1999). For instance, the sentence “m m m my name is
Jagadeesh” has three repeated units.
When a speaker interrupts the forward flow of speech and restarts or changes the
utterance they had originally planned to speak, the result is a false start or a revision
(e.g. “This is a blue – a purple bag”). The modification may be in terms of replac-
ing the word with an entire new word as in the previous example or insertion of a
word in a word sequence (e.g. “This is a bag – blue bag”). Changes in the gram-
matical structure of the sentence are also called revisions (e.g. “I will – I shall do it”).
False starts or revisions can thus serve as self-repair strategies as well. Parenthetical
remarks are words or phrases that are meaningful in nature but not appropriate for
the sentence (e.g. “I mean, like, you know, well”). Interjections are the addition of
extraneous sounds that are meaningless in nature (e.g. “uh, um”). It may be recalled
that these examples (of interjections and parenthetical remarks) were also given
while mentioning filled pauses. Interjections and parenthetical remarks are thus,
often used to fill pauses when the speaker may not want to remain silent for a long
time between two words. These utterances may be repeated by the speaker several
times. Similar to repetitions, the frequency of false starts, parenthetical remarks and
interjections can also be calculated as a percentage.
The next two chapters would get the reader familiarized with stuttering, one of
the various fluency disorders. In persons who stutter (PWS), apart from the above-
mentioned disfluencies, another common type of speech discontinuity or disfluency
4 Santosh Maruthy
Rate of speech
Rate of speech or speech rate is the second dimension of fluency. It refers to the
speed with which one can speak. Speech rate could be influenced by mood, envi-
ronment, linguistic structure, a person’s age, culture, speed of articulatory movement
and co-articulation. As per the definition of fluency (Starkweather, 1987), fluent
speech is uttered at a rapid rate. However, speech rate varies continuously based
on the situation. Speech rate may be measured in syllables per second, syllables per
minute or words per minute. It can be calculated using the formula:
Astr. Now from the holy records, from the creed of the Magus
Zoroaster, from the Greek, and Roman, and other legends, how clear
is the influence of ethereal beings, of angels and demons, on man’s
life; and of the imparted power of exorcism! In allusion to this divine
gift to Solomon, Josephus has the following story:—“God also
enabled him to learn that skill which expels demons, which is a
science useful and sanative to men. And this method is of great
force unto this day, for I have seen a certain man of my own
country, whose name was Eleazer, releasing people that were
demoniacal in the presence of Vespasian, and his sons, and his
captains, and the whole multitude of his soldiers. The manner of the
cure was this. He put a ring, that had a root of one of those sorts
mentioned by Solomon, to the nostrils of the demoniac, after which
he drew out the demon through his nostrils; and when the man fell
down immediately, he adjured him to return into him no more,
making still mention of Solomon, and reciting the incantations which
he composed. And when Eleazer would persuade and demonstrate
to the spectators that he had such a power, he set a little way off a
cup or bason full of water, and commanded the demon, as he went
out of the man, to overturn it, and thereby to let the spectators
know that he had left the man.”
The gods of the Greeks and the Latins, the lares and lemures, or
hearth-spirits, the pagan and the Christian elves, were ever held as
delegated agents of the Deity, who worked, not by a fiat, but by an
instrument. Such were the Cemies of the American islanders, and
the Kitchi and Matchi Manitou of the Indians; and, if we consult
Father Borri, we shall learn that in Cochin China Lucifer himself
promenaded the streets in human shape.
Psellus records six kinds of devils; and the arrangements of
Agrippa, and other theologians, enumerate nine sorts of evil spirits,
as you may read in one of old Burton’s eccentric chapters.
The mythology of the Baghvat Geeta, the sacred record of the
Hindoo theists, is based on the notion of good and evil spirits, the
emblems of virtue and of vice under the will and power of Brahma.
Indeed, the Hindoo mythology is but that of the classic in other
words. Agnee, the god of fire, Varoon, the god of the ocean, Vayoo,
the god of the wind, and Cama, the god of love, are but other
names for Jupiter, and Neptune, and Œolus, and Cupid.
The creed of Zoroaster asserts a perpetual conflict between the
good and evil deity, the types of religious knowledge and ignorance.
The southern Asiatics are people of good principle, and the northern
nations people of evil principle. And why may not the Persian thus
coincide with Bacon himself, who in his book “De Dignitate,”
confesses his belief in good and bad spirits, in charms, and
prophecies, and the varieties of natural magic. Or is it inconsistent
that the Hindoos should incarnate the malignant disease, small pox,
in the person of the deity Mah-ry-umma, of whose lethal influence
they lived in abject fear.
Ida. In the holy records, it is true, we read that demons were
even permitted to enter the bodies of other beings, and that when
they had so established a possession, by divine command they went
out of those possessed, as, for sacred example, into the herd of the
Gadarenes; that they were also commissioned, for the fulfilment of
the inscrutable will of the Creator, to try the endurance of Job, and
even to tempt the divinity of the Saviour, and that they were the
immediate cause of madness and other sad afflictions.
I do fear, Astrophel, that there is much danger, now, in this
embodying of a demon; and that we too often model our modern
principles, on the proud presumption of still possessing that
miraculous power of exorcism. With sorrow may I confess, that the
holy truths of Scripture, so clearly evincing a special purpose, should
have been ever warped, by worse than inquisitorial bigotry, into the
motive for cruelties unparalleled. From the Scripture histories of
demoniac possession have arisen the coercion and cruelties, which
once marked with an indelible stain the records of our own
madhouses; where chains and lashes, inflicted by the demons of
science, have driven the moody wretch into a raving maniac, when a
light hand and a smile would have brought back the angel reason to
the mind.
Impersonation is the grand source of many similar errors. The
demon, which, since the light of the Christian dispensation has
brooded in man’s heart and mind, is his own base passion, which
incites him to shut his eyes to this holy light, and follow deeds of
evil; to be a slavish worshipper in the hall of Arimanes. With this
profane homage, we court our evil passions, to betray and destroy
the soul. And this is the interpretation of an allegory in the profane
legends of the Talmud—that Lilis, the wife of Adam, ere the creation
of Eve, brought forth none but demons; the origin, indeed, of moral
evil.
There are many popular stories which bear a moral to this end:
that the evil spirit is powerless over the heart, if it be not
encouraged and invited; and, alas! the alluring masque under which
evil looks on us, is often but too certain to charm us to its influence,
or we are too thoughtless to beware the danger. Thus the disguised
enchanter enters into the palace of the Sultan Mesnar, (in “The Tales
of the Genii,”) and thus the gentle Christabel of Coleridge leads the
false Geraldine over that threshold, which she could not cross
without the help of confiding and unsuspecting innocence.
Cast. The crones of retired villages have not yet yielded their
belief in fairy influence.
Among the low Irish it is believed that (as the nympholepts of old
who had looked upon Pan, sealed an early doom), the paralytic is
fairy-struck; and superstition has inspired them with a belief in the
influence of the evil eye or glamourie, especially in the vicinity of
Blackwater.
I remember, when our wanderings among the Wicklow
mountains led us through the dark glen of the Dargle, the implicit
faith of the Irish women in the charm of amulets and talismans. Like
the fabled glance of the basilisk, the evil eye is bestowed on some
unhappy beings from their very birth; nay, the spell infests the cabin
in which they herd. To avert this fatal influence from the children, a
charm is suspended around their necks, which when blessed by the
priest is called a “gospel.”
When a happy or evil star shines at a birth, it is the eye of a
cherub or a demon, smiling or frowning on the destiny of the babe;
and when happiness or misery predominates in a life, it is a minister
of good or ill that blesses or inflicts. There is one beautiful scrap of
this mythology—the thrill of holy joy which the Irish mother feels
when her infant smiles in its sleep; for she knows it is a holy angel
whispering in its ear.
In our own island they are often celebrated as the very pinks of
hospitality.
In Cornish history, we read how Anne Jeffries was fed for six
months by the small green people. And in yonder forest of Dean, (as
writeth Gervase, the Imperial Chancellor, in his “Otia Imperialia,”) “In
a grovy lawn there is a little mount, rising in a point to the height of
a man, on which knights and other hunters are used to ascend,
when fatigued with heat and thirst, to seek some relief for their
wants. The nature of the place and of the business is, however,
such, that whoever ascends the mount must leave his companions
and go quite alone. When alone, he was to say, as if speaking to
some other person, ‘I thirst,’ and immediately there would appear a
cup-bearer in an elegant dress, with a cheerful countenance, bearing
in his outstretched hand a large horn, adorned with gold and gems,
as was the custom among the most ancient English. In the cup,
nectar of an unknown but most delicious flavour was presented; and
when it was drunk, all heat and weariness fled from the glowing
body, so that one would be thought ready to undertake toil, instead
of having toiled. Moreover, when the nectar was taken, the servant
presented a towel to the drinker to wipe his mouth with, and then,
having performed his office, he waited neither for recompense for
his services, nor for questions, nor inquiry.”
This frequent and daily action had, for a very long period, of old
times taken place among the ancient people, till one day a knight of
that city, when out hunting, went thither, and having called for drink,
and gotten the horn, did not, as was the custom, and as in good
manners he should have done, return it to the cup-bearer, but kept it
for his own use. But the illustrious Earl of Gloucester, when he
learned the truth of the matter, condemned the robber to death, and
presented the horn to the most excellent king, Henry the Elder; lest
he should be thought to have approved of such wickedness, if he
had added the rapine of another to the store of his private property.
But the fairies might rue their kindness, if you frowned so darkly
on them, Astrophel. They would fear the influence of your spells, for
there is blight and mildew in that glance. At the banquet of the
fairies, if the eye of the seer but look on them, the romance is
instantly at an end: the nymphs of beauty are changed into withered
carles and crones, and the splendour of Elfin-land is turned to dust
and ashes.
Ida. As a set-off against the virtues of your fairies, Castaly, you
forget there was a propensity to mischief. They were rather fond,
like the Daoine Shi, of stealing unchristened babes, and of chopping
and changing these innocents, thence called changelings. On this
fable your own Shakspere has wrought the quarrel of Oberon and
Titania: —
Cast. We have risen with the lark to salute you, Astrophel. And
you have really slept in Tintern Abbey? Yet not alone; “I see queen
Mab hath been with you,” and brushed you with her wing as you lay
asleep.
Astr. Throughout the live-long night, sweet Castaly, I have
revelled in a world of dreams. My couch and pillow were the green
grass turf. No wonder that tales of the times of old should crowd on
my memory, that elfin lips should whisper in my ear —
Cast. “The soft exquisite music of a dream.”
Ida. Talk not of dreams so lightly, dear Castaly; the visions of
sleep are among the most divine mysteries of our nature: these
transient flights of the spirit in a dream, unfettered as they seem by
the will, are, to my own mind, among the most exalted proofs of its
immortality. Is it not so, Evelyn?
Ev. The mystery which you have glanced at, Ida, is the most
sublime subject in metaphysics. Yet in our analysis of the
phenomena of intellect, it is our duty to discard, with reverential
awe, many of the notions of the pseudo psychologists in allusion to
that self-evident truth, that requires not the support of such
arguments.
In tracing the mystery of a dream to its association with our
immortal essence, reason will at length be involved in a maze of
conjecture. True philosophy will never presume to explain the
mystical union of spirit and of flesh; she would be bewildered even
in their definitions, and would incur some peril of forming
unhallowed conclusions. Even the nature of the rational soul will
involve him in endless conjecture, whether it be fire, as Zeno
believed; or number, according to Xenocrates; or harmony,
according to Aristoxenus; or the lucid fire—the Creator of all things,
of the Chaldean astrologers.
He who aspires to a solution of the mystery, may wear out his
brain in the struggle, as Philetas worked himself to death in a vain
attempt to solve the celebrated “Pseudomenos,” the paradox of the
stoics; or, like the gloomy students of the German school, he might
conclude his researches with a question like this rhapsody—
unanswerable.
“But thou, my spirit, thou that knowest this, that speakest to
thyself, what art thou? what wast thou ere this clay coat was cut for
thee? and what wilt thou be when this rain-coat, this sleeping-frock,
fall off thee like a garment torn to pieces? Whence comest thou?
where goest thou? Ah! where from and to, where darkness is before
and behind thee? Oh ye unclothed, ye naked spirits, hear this
soliloquy—this soul-speech. Know ye that ye be? Know ye that ye
were, that ye are as we are or otherwise, in eternity? Do ye work
within us, when a holy thrilling darts through us like lightning, where
not the skin trembles but the soul within us? Tell us, oh tell us, what
then is death?”
Now, if we reflect on the psychology of the Greeks, can we
discern their distinctions of νους, πνευμα, ψυχη, σωμα, of soul or
spirit—of spiritual body, or of idol and of earthly body; or of θυμος,
ψυχη, and νους, ψυχη, and so forth?
This fine distinction may be reduced to one simple proposition:—
that soul and mind are the same, under different combinations:
mind is soul evinced through the medium of the brain; soul is mind
emancipated from matter. This principle, if established, might
associate the anomalies of many sophists; the existence of two
minds, the sensitive and intellectual, taught by the Alexandrian
philosophers, or the tenets of Bishop Horsley, in his sermon before
the Humane Society, the separation of the life of intellect from
animal life; and it might reconcile the abstract reasoning of medical
philosophy, with the pure but misdirected arguments of the
theological critic.
We believe the spirit to be the essence of life and immortality;
and it signifies not whether our words are those of Stahl—that it
presided over the animal body; or those of Galen and Aristotle—that
it directed the function of life. It is enough that we recognize the
πνοη ξωης, or that breath of life, which the Creator breathed into
none but man; and the εικων θεου, the image of God, in which he
was created. In this one proposition all the points of this awful
question are comprehended. And it is on this combined nature that
we must reason, ere we discourse on sleep and dreams.
Cast. I condole with you, Astrophel; you must forget the
splendour of your dreams, and listen to their dull philosophy.
Astr. We may indeed sympathize with each other, Castaly; we are
threatened with another abstruse exposition of the mind, although
we are already sated with the contrasted hypotheses of our deepest
philosophers: the cogitation or self-reasoning of Descartes, (the
essence of whose “Principia” was “Cogito, ergo sum;” and it is an
adoption of Milton’s Adam, “That I am, I know, because I think:”
forgetting that the very ego which thinks, is a proof of prior
existence;) and of Malebranche, who believed they existed because
they thought; the abstract spiritualism of Berkley, who believed he
existed merely because others thought of him; the consciousness of
Locke; the idealism of Hume; the material psychology of Paley; the
mental corporeality of Priestley; and the absolute nonentity of
Pyrrho.
Ev. I leave these hypotheses to speak for themselves, Astrophel;
my own discourse will be wearying enough without them.
Over the intricate philosophy of mind, Creative Wisdom has
thrown a veil, which we can never hope to draw aside. True, the
beautiful mechanism of its organ, the brain, is apparent; and we can
draw some analogies from inspection of the brain of a brute, and its
progressive development in fœtal life, in reference to comparative
simplicity and complexity; but its phenomena are not, like most of
the organic functions of the body, demonstrable.
Now, although we know not the mode of this mutual influence,
the seat of mind is a subject of almost universal belief; not that
Aristotle, and Ætius, and John Locke, are our oracles on this point,