Mixed stuttering is a disorder of smooth speech caused by the presence of tonic and clonic convulsions of articulatory muscles, developing against the background of residual phenomena of central nervous system damage and accompanied by neurotic layers. At first it proceeds as an organic stuttering, later due to the addition of neurotic disorders it acquires the features of logoneurosis. Mixed stuttering is diagnosed according to neurological, speech therapy and psychological examinations. Treatment includes sedative, neurotropic, vascular, dehydration therapy, speech therapy, psychological correction and psychotherapy.
General information
Mixed stuttering is a combination of neurotic (functional) and neurosis-like (organic) stuttering. Such stuttering contains both an organic and a psychological aspect of speech disorders. Mixed stuttering is formed when neurotic disorders gradually develop against the background of a long-term neurosis-like form of stuttering. The latter are most often associated with existing speech disorders and their consequence — logophobia, i.e. the fear of speaking. In this regard, mixed stuttering is referred to by some authors as “neurosis-like stuttering with neurotic layers”. The polymorphism of the etiology and pathogenetic mechanisms of the formation of a mixed form of stuttering make it the subject of joint management of specialists in pediatrics, neurology, speech therapy, psychology and psychiatry.
Causes
At its core, mixed stuttering has an organic substrate, i.e. structural changes in the central nervous system, as a rule, representing residual (residual) phenomena of perinatal adverse effects. The latter include: intrauterine infections (cytomegaly, herpes, syphilis, etc.) and intoxication (with smoking, drug addiction or alcoholism in a pregnant woman, exposure to harmful environmental factors on her body), fetal hypoxia (due to toxicosis of a pregnant woman or fetoplacental insufficiency), birth trauma of newborns, asphyxia of newborns, prematurity.
The second group of reasons that cause the formation of a mixed form of stuttering are psychogenic factors. More often these are chronic stressful situations associated with an unfavorable psychological climate in the family, increased demands on the child, information overload. Perhaps the influence of acute psychotrauma, in the role of which children are most often frightened. It should be understood that the existence of organic stuttering in itself is a source of constant stress for the child. However, against the background of a favorable psychological climate, its negative impact on the child’s psyche will be expressed to the least extent.
Organic factors induce the development of neurosis-like stuttering, which manifests during the formation of the child’s speech. Psychogenic triggers lead to the appearance of signs of neurotic stuttering (logoneurosis) against the background of an existing speech disorder. This usually manifests itself clinically after the age of 10. The functional and morphological basis that causes mixed stuttering are tonic, clonic and clonic-tonic convulsions of articulatory muscles. At the beginning, the clonic version of seizures prevails, leading to the repetition of initial sounds or syllables in the word (s-s-dog, mo-mo-milk). Then the number of tonic convulsions increases, manifested by pauses in words (with… tul, kar…toshka).
Symptoms
Mixed stuttering, as well as neurosis-like, debuts after 3 years, during the formation of speech skills. Initially, its manifestations are similar to the symptoms of organic stuttering. Speech is accelerated (tachylalia), but at the same time monotonous and muffled, accompanied by monotonous gestures. Sound reproduction is characterized by dyslalia, dysarthria is possible. Stuttering is accompanied by respiratory disorders — it is more superficial and discoordinated, occurs with weak involvement of the diaphragm.
Phonemic hearing is impaired, which allows you to distinguish the sounds of your native language. Speech activity is increased, fixation on a speech defect and logophobia are not observed. During this period, stuttering has a constant course with temporary deterioration due to overwork, somatic diseases.
Mixed stuttering occurs against the background of delayed psychomotor development. There is clumsiness, stiffness and stereotyped movements, some slowness, awkwardness, lack of fine motor skills. Asthenic syndrome, enuresis, sleep disorders, involuntary muscle contractions (tics), expressed mainly in the facial muscles, are possible. If, normally, the formation of speech ends around the age of 7, then a child with mixed stuttering, with age, there is an aggravation of speech dysfunction and an increase in disorganization of speech. Over time, when a child starts school, dyslexia (impaired reading ability) and dysgraphy (spelling mistakes) are detected.
With age, the child becomes aware of his own speech defect. He begins to “mask” his stuttering, avoiding pronunciation of difficult words and using various speech techniques (for example, speech stretching). Speech activity decreases. Mixed stuttering is formed. The child is embarrassed to speak in front of strangers, refuses to speak in front of an audience. Stuttering acquires neurotic features: it increases with excitement, in an unfamiliar environment. Speech defect prevents the child from communicating his opinion and feelings to others, is an obstacle in communication. Against this background, neurotic layers arise: anxiety, various fears (primarily logophobia), suspiciousness.
Mixed stuttering transforms from constant to undulating. His symptoms worsen after a psychoemotional overload (exam, disco, showdown), with a sudden change in the situation, the need to talk to unfamiliar people. Conversely, in a familiar and calm environment, there is a significant decrease in the intensity of stuttering. In a dysfunctional psychological atmosphere, neurotic symptoms can worsen, leading to the appearance of depressive neurosis, hypochondria, obsessive-compulsive neurosis, hysteria, etc. Often mixed stuttering is accompanied by autonomic dysfunction.
Diagnostics
Diagnosis of mixed stuttering is possible: the presence of a corresponding speech defect and neurotic disorders, anamnestic data about perinatal pathology and delayed psychomotor development. Diagnosis is carried out collectively by a speech therapist, a neurologist and a child psychologist. In order to exclude ENT pathology, an otolaryngologist’s consultation is prescribed. The study of oral speech determines tachylalia, the absence of general smoothness of speech and a decrease in its intonation expressiveness, the presence of stutters, stretching sounds and repetitions, accompanying speech movements (tics, gesticulation). Diagnostics of auditory-speech memory reveals its decline and the presence of phonemic perception errors. Schoolchildren are additionally diagnosed with written speech.
Objective neurological examination is necessarily supplemented by instrumental studies: EEG, REG, Echo-EG. Often, echoencephalography diagnoses subcompensated hydrocephalus, and EEG – increased convulsive readiness. According to indications, an MRI of the brain is performed to exclude an intracerebral tumor, cerebral cyst, occlusive hydrocephalus. Since mixed stuttering has psychological aspects, patients are recommended to consult a psychologist with a comprehensive examination, including neuropsychological research, psychological testing and diagnosis of personality traits.
Treatment
Mixed stuttering requires complex therapy against the background of a protective regime in a friendly psychological environment with the exception of stressful influences. Strict adherence to the daily routine is recommended (for children — necessarily with a nap), sports games, walks, hardening, physical therapy. Treatment consists of three components: elimination of neurological disorders of organic genesis and improvement of cerebral metabolism, speech therapy correction and psychological (psychotherapeutic) assistance.
Pharmacotherapy may include sedatives (mebikar, magnesium lactate + B6, valerian extract, lemon mint and peppermint extract, thioridazine, phenibut, dicalia clorazepate), vitamins gr. B and folic acid, vascular drugs (vinpocetine), nootropics (glycine, hopanthenic acid, ginkgo biloba, piracetam). In hydrocephalus, dehydration therapy with acetazolamide is indicated. Correction of speech disorders is carried out by regular classes with a speech therapist. The combined treatment may include reflexotherapy methods and physiotherapy (electroson, collar zone massage, electrophoresis).
Psychotherapeutic help plays an important role. It is aimed at preventing the pathological formation of personality, solving existing psychological problems. Classes with a psychologist, psychotherapy, neuropsychological correction, art therapy are recommended for children. A mandatory point is psychological counseling of parents. Older children use group psychological trainings, training in relaxation techniques and self-control of speech. In difficult cases, hypnosis and suggestive therapy may be used.
Prognosis and prevention
The combined nature of the etiopathogenetic mechanisms that form mixed stuttering causes its more complex correction in comparison with neurotic and neurosis-like forms. However, timely complex therapy of mixed stuttering can prevent its negative impact on the emerging psyche of the child and social adaptation.
Preventive measures include all measures to prevent perinatal pathology of the central nervous system, timely and correct treatment of the consequences of perinatal damage to the central nervous system, prevention of traumatic factors and psycho-emotional overload in the child’s life.