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INSTRUMENTAL SIDE A DEFICIT DISORDERS Stuttering or stammering J. Sangorrín Abstract O stuttering stuttering.Among the many verbal fluency disorders, stutt ering is a special rhythm of speech disorder characterized by disfluencies consi sting of repetitions and prolongations of speech sounds and difficulty starting the sentence, even though the subject knows what to say. The stuttering is impos sible to circumvent and the subject reacts to stress and strain behavior to spea k, adding also avoidance and escape, logofobia and negative impact on school per formance, social and work later. Stammering or stuttering typically begins in th e preschool years, about 3 years old, with no in most cases a ground trigger. In general, there is a familial component of susceptibility to stuttering. The dis order is not the consequence of a psychopathological problem, but rather negativ e psychological consequences to become chronic and complicated evolution. Unlike the usual lack of fluidity of all preschool children, stuttering occurs in 5% o f these children, who can be identified in time to facilitate the flow of your s peech and prevent the consequences of its persistence or chronicity. Although it is a separate disorder, is a frequency of comorbidity with other disorders (lan guage delay, speech delay and anxiety) higher than normal. [Rev Neurol 2005; 41 (Suppl 1): S-43-6] Keywords. Anxiety. Stuttering. Disfluency. Cerebral dysfuncti on. Creep. Social phobia. Logofobia. Stuttering. INTRODUCTION A number of pathological conditions in the nervous system can cause alterations in the flow of speech (disfluencies) in children and adults, brain diseases and injuries (for neonatal anoxia, cerebral palsy, epilepsy, head traum a, stroke, dementia, etc. .) and other brain dysfunction can disrupt the flow of speech in different ways. DISORDERS OF SPEECH FLUENCY Neurogenic Stuttering (St uttering acquired) The speech disfluency starts from an injury or brain disease in a subject who previously had normal conditions for fluent speech and / or a n ormal fluent speech. In these disorders, fluency failures tend to be stable over time and in different situations, verbal, ie no oscillations, without adapting to the fluidity, and without expressing anxiety about stuttering (as opposed to stuttering in that there are oscillations , adaptation to the fluidity and anxie ty). Research in Neurogenic stuttering is providing data relevant to the underst anding of stuttering, which is not, in most cases, associated with brain damage, but which it accepts the existence of a dysfunctional factor in the central ner vous system demonstrable by neuroimaging. Unlike psychogenic stuttering stutteri ng, begins in adults without neurological cause, with little emotional impact. I t is a very rare disorder, whose cause is a stressful episode. Accepted: 06/13/1905. Psychiatry Service. Hospital Universitari del Mar. Barcelo na, Spain. Correspondence. Dr. Javier Sangorrín. Psychiatry Service. Hospital Un iversitari del Mar. Passeig Maritim, 25-29. 08003 Barcelona. © 2005 JOURNAL OF N EUROLOGY Stuttering or stammering (stuttering), or developmental stuttering (Developmenta l stuttering) the stuttering begins in childhood, typically between 2 and 4 year s old, usually coinciding with the emergence of language online, or when the chi ld moves use of expressions of a word to combine several words forming the first sentences. Exceptions are cases of children with developmental delay or speech language or Down syndrome, in which the stuttering starts later. In most cases, stuttering begins without apparent triggers. In a subset of cases involve stress ful triggers, in this subgroup, the existence of a family history of stuttering is less frequent than in a large group, and they are typical personality profile s with high emotional reactivity and / or anxiety traits [18 ]. The nuclear beha vior of stuttering is the disruption of coarticulation [25], mostly at the begin ning of the sentence, resulting in different disfluencies (repetitions of syllab les, long silences or sound of word sounds), although the person knows what he m eans and how it is said, with increased muscle tension and stress behaviors to s peak, as the child recognizes the difficulty. When the condition persists for mo re than two years from the beginning,€becomes chronic and complicated by other s ymptoms (logofobia, avoidance behavior, feelings and negative attitudes towards communication) often disturbing social performance, and later academic work. Taq uifemia (cluttering) particular developmental disorder, the type of stuttering, with disfluencies together with unintelligible speech and too fast. It seems to affect the patient less stuttering and, in principle, can be more controllable. Covert Stuttering (covert stuttering) The patient shows difficulties for the nor mal fluid coarticulation. However, this difficulty is hardly noticeable to the l istener. It occurs in individuals who have suffered from a disorder of stutterin g in the past, which have improved the flow of speech but still perceived diffic ulty speaking fluently and have a Rev Neurol 2005; 41 (Suppl 1): S43-S46 S43 J. SANGORRÍN weak or inconsistent flow. This form of stuttering also occurs in some individua ls with social phobia, who appreciate difficulties (rather subjective) to speak with sufficient fluency. Among the various disorders of speech fluency, stutteri ng is a disorder of fluency par excellence. Stuttering (stuttering) The stutteri ng is a clinical syndrome characterized by abnormal and persistent disfluencies of speech, accompanied by peculiar behavioral patterns, cognitive and affective. The patient knows exactly what to say but is unable to speak with normal flow c aused by involuntary repetitions, prolongations, or interruptions in producing m ovements of speech and, consequently, the flow verbal sound. It has been conside ring the stuttering as a special disorder (idiopathic stuttering) without being a clear etiology, unable to define a brain pathology. However, recently, evidenc e from functional brain imaging [1] and cognitive evoked potentials [5] describe functional brain abnormalities related biological basis of stuttering. Are even finding differences in the volume of brain structures related to the flow of sp eech in the brain of patients dysphemisms compared with the brains of people flu ent [6,7]. They are also described changes in these structural and functional br ain abnormalities after stuttering therapy [10]. It has long been accepting of s tuttering as a disorder of cerebral physiological origin (not caused by another disorder psychopathology). The prevalence of this disorder in the population is 0.75%, even at preschool age is estimated that about 5% of children experience a period of stuttering for a few months. This stuttering is abnormal in the perce ntage of preschool and distinguishable from the typical lack of influence (or 'n ormal non-fluency') of all children of this age. Therefore, not all preschool ch ildren stutter, but only 5%. Here the term 'evolution' should not be used to des cribe the 'lack of fluency that is normal' in all preschool children (normal non -Fluency). Stuttering or dysfluency is not unlike the normal flow, especially fo r the speed of the repetitions and the short duration of the vowels in the repet itions, prolongations of speech sounds with excessive muscle tension, blockages motorverbales, and Conduct effort to speak. In some cases, may not be easy to de termine if the flow is normal or not, and require careful consideration. These p reschool children who stutter, ie where the speech is significantly different to the 'normal non-fluency' can and should be identified as soon as possible, as t his can contribute to intervene and minimize the risk that these children develo p a stuttering complicated. While natural growth plays in many cases for the dev elopment of fluent speech, in some cases among young children this disorder can be serious, complicated and even at this age, difficulties in communicative beha vior. Four out of five children who stutter, in preschool, will overcome the pro blem in childhood. One, therefore, of those five children will have a disorder o r chronic persistent stuttering. Preschool children who stutter outnumber girls in frequency (3-2). This proportion increases with age (5-1), ie, girls solve the problem more easily than boys. Among children who stu tter in preschool, it is estimated a remission of the disorder in 80% of cases, within two years following the appearance of it, especially when the child recei ves adequate treatment speech. Early intervention, including counseling parents, €and treatment of children under the necessity of the case can extend the possib ilities of solving the problem. You can always and should be reduced complicatio n or worsening the condition commonly occur in those cases in which persists dur ing childhood and tends to become chronic. Personality The stuttering is a speec h disorder in its own right and generally not associated with other disorders of speech or language. The vast majority of people who stutter do not have a parti cular psychological profile similar, they are equal in intelligence, development , neuroticism, culture, education and personality that people fluent. Parents of children dysphemisms not have a distinct personality profile that parents of fl uent children. However, clinical observation shows that in a large group of chil dren dysphemisms consistently given some special conditions: perfectionism, anxi ety and emotional sensitivity, which could be considered as companions and predi sposing factors (if not cause) of the stuttering. In any case, there is a fragil ity in the fluidity of speech disfluencies may result in further exacerbation in emotionally charged situations. The emotional impact of the stuttering occurs m ore or less number and severity of disfluencies, common characteristic being the great variability of this disorder among patients and also in the same patient at different times and circumstances. Some patients with mild disfluency schedul ed by the perception of the partner may suffer a high social anxiety in dialogue with others and therefore perform many avoidance behaviors and impaired social communication performance. At the other extreme, however, some patients, showing a marked dysfluency, may not only suffer from difficulties in communication wit h others. In the first group are dysphemisms that would meet clinical criteria f or social phobia or covert stuttering. Both groups, however, are exceptions that prove the rule: the vast majority of accused dysphemisms communicative anxiety levels to the severity of their disfluency [15.18]. Genetics and language, stutt ering occurs mostly in certain families. The risk of PTSD among family members v aries by sex and family sex dysphemism. Thus, in general, for a man stuttered pr obability is calculated that 9% of their daughters and 22% of their children who stutter, while for a woman who stutters, the risk is higher. In monozygotic twi ns, the risk reaches 75%. It admits the existence of a genetic predisposition to develop a stuttering, although it is unclear to what extent in determining the severity of the condition or its possible chronicity. Genetic alterations have b een identified among samples from dysphemisms (long ago found an altered geS44 Rev Neurol 2005; 41 (Suppl 1): S43-S46 INSTRUMENTAL SIDE A DEFICIT DISORDERS common netic stuttering, Tourette syndrome and attention deficit disorder, and m ore recently have found abnormalities in genes 13 and 18 in subjects dysphemisms ), although not yet well known penetration factor of the genetic factor predispo sition to stuttering. Currently investigating the genetics of stuttering, but it also examines the conditions of emotional and linguistic development of this di sorder. The age of onset of stuttering is located, in 90% of cases, between 25 a nd 41 months, a period in which children move from a verbal expression limited t o the use of isolated words, the acquisition of so-called 'language online '(phr ase). While stuttering is a disorder distinct from speech delay, stuttering inci dence is higher among children with language delays. There is even a greater per sistence of stuttering in these cases. This shows that there is an implication o f language development in the genesis of stuttering. Research currently being in vestigated stuttering from different scientific perspectives (genetic, phoniatri c, neurophysiological, neuropsychological and psycholinguistic) and increasingly interdisciplinary, having fallen into disuse old psychodynamic and behavioral t heories. Along with simple theories of stuttering [24,25] to explain the proxima te cause of stuttering in terms of muscle abnormalities in behavior, theories ar e developed inclusive of all neuropsicolingüísticos factors [13]. On the other h and are considering experimental studies with functional brain imaging in conjun ction with psycholinguistic studies of special scientific interest.€Other invest igations, such as environmental factors and their influence on stuttering, are c omplicated to make due to methodological difficulties and have fallen a bit into disuse, although it is necessary to decode them into account its relationship w ith the genetic factor contributing to better understand the causes of stutterin g. Treatment and prevention The treatment for stuttering is speech therapy with elements of psychotherapy. Several procedures are used: - Teaching the mechanics of speech. - Observation of behavior in speech. - Techniques of fluency. - Musc le relaxation techniques and vocal control. - Techniques for correction of stutt ering. - Social skills training. - Psychotherapy Cognitive and attitudinal chang e, and reduction of speech-related anxiety and defensive reactions. - Modificati on of the patient's environment to eliminate the conditions that exacerbate or m aintain stuttering. In developing treatment programs for children with stutterin g takes into account both the aspects of communicative interaction and the limit ations of the motor-verbal behavior. The clinical evaluation is weighted the wei ght of individual factors (the genetic, psychic development and language of the child, the onset and development of stuttering, the frequency and type of disflu ency on the voltage-fragmentation model of speech The social status and family c ommunication and interaction effect tion on the fluidity of the child). We evaluate the severity of the disorder acc ording to the characteristics of disfluency, the presence or absence of associat ed problems, the concern in the child or the environment and the risk of develop ing a stutter. The classic attitude of 'wait' before stuttering young child diag nosogénica derived from the theory [8] and still remains in effect for some in o ur days, is changing due to intervene in these early ages. Johnson's slogan ("le t alone children who stutter ') has lost credibility in the light of new scienti fic contributions. Is now beginning to say that children at risk of becoming chr onic stutterers can and should be identified and treated as soon as possible to facilitate the development of fluency and eliminate factors of attachment, maint enance and chronicity of the disorder. Pediatricians are key in preventing, mana ging these children at risk of a specialist in the treatment of stuttering. They should know that not all of these children at risk have the potential to develo p fluency of speech with ease. The board of 'wait, because eventually it'll go a way' does not stand up scientifically in the case of stuttering. Through longitu dinal research studies [25.27-29] criteria are available to identify, even the p hysical aspects of stuttering in young children that relate to chronic stutterin g, having improved considerably the possibilities in the diagnosis and early pro gnosis. On the other hand, speech therapists and language need specialized train ing in the treatment of stuttering as a condition to adequately address the most effective and disorder. Early intervention programs that currently are used hav e the following objectives: - Mark the disfluency and assess the risk of complic acióncronificación (high risk / low risk / no risk). - Provide advice to parents on the basis of established risk factors of behavior patterns that optimize the conditions for more fluent speech. In addition to this indirect intervention (o n the environment) are also involved directly on the child in varying degrees de pending on the severity and extent and risk of cases the rate of evolution and f actors relating to language and interpersonal stress, with the participation of parents in the therapeutic process. The child can be trained in modeling of flue nt speech, social skills, handling pressure on speech and behavior modification effort. The treatment of stuttering requires modifying environment variables and of himself, always in the context of everyday life, because otherwise, even if they can achieve fluent speech in a controlled situation such as the therapy ses sion, it would completely useless if the problem would improve the daily dialogu e within the family and school. The intervention would align the demands of flue ncy around the child's abilities and it has better personal and environmental co nditions for a more fluent speech, has the sense of mastery of their language an d maintain a normal communicative behavior.€Recent studies show that early inter vention can prevent the development of stuttering and that the earlier the inter vention, the better the long-term results [9,11,12,14]. In general there is a se nse optimistic about the therapeutic possibilities of early intervention. The ob Rev Neurol 2005; 41 (Suppl 1): S43-S46 S45 J. SANGORRÍN intentions of chronic stuttering results depend on identifying and modifying the factors responsible for this disorder. Perhaps the causes of chronic stuttering differ from other forms of stuttering (stuttering developmental stuttering reme diable). In more resistant cases, the purpose of treatment can not be, for now, fully fluent speech, but more fluent speech, stuttering with a softer, extrovert ed behavior and the behavior control effort. It can also prevent the complicatio n largely typical of stuttering, ie, learning of adverse reactions to stuttering , as well as the mismatch and impairment in social, academic and labor is often associated with chronic stuttering. In older children, adolescents and adults, t here are two types of therapeutic approach that arise today in the context of sp eech therapy: Some programs are based on the modeling of fluent speech or speech modification and correction stuttering, raising target to achieve a fluent spee ch. The other type of approach raises more about desensitization to stuttering d isfluencies working towards a more fluid, with tolerance and acceptance of it. TERMS AND CONDITIONS ASSOCIATED WITH POTENTIAL stuttering stuttering occurs with much greater frequency in Down syndrome. There is a greater risk of stuttering in normal children who have suffered anoxia at birth, and also in the presence o f hearing abnormalities. In a sample of 550 patients dysphemisms [23] found a si gnificant presence of comorbidity of other clinical entities in stuttering: spee ch disorder (13%) and language (14%) and anxiety disorders (16%). We found no st atistically significant comorbidity of mental retardation (other than Down syndr ome), psychomotor retardation, conduct disorder, personality disorder, obsessive -compulsive disorder, tics, attention deficit disorder, epilepsy or affective di sorder [23]. In principle, the stuttering is a disorder per se, as distinct from other disorders. 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