Samenvatting Zorgtraject Vloeiendheid
Prof. Ellen Rombouts – 2024-2025
Hoofdstuk 1: Types van vloeiendheidsstoornissen ...................................................................................... 6
1.1 Vloeiendheidsstoornis ............................................................................................................... 6
1.2 Stotteren en broddelen .............................................................................................................. 6
1.3 Types stotteren .......................................................................................................................... 6
1.4 Ontwikkelingsstotteren .............................................................................................................. 7
1.4.1 Kenmerken ............................................................................................................................ 7
1.4.2 Drie facetten die meespelen ................................................................................................... 7
1.4.3 Insider perspectief ................................................................................................................. 9
1.4.4 Fenomenen bij ontwikkelingsstotteren.................................................................................. 10
1.5 Neurogeen stotteren ................................................................................................................ 10
1.6 Psychogeen stotteren .............................................................................................................. 11
1.7 Farmacogeen stotteren ............................................................................................................ 11
1.8 Geveinsd stotteren................................................................................................................... 12
1.9 Broddelen ................................................................................................................................ 12
Hoofdstuk 2: Hoe ontstaat ontwikkelingsstotteren?.................................................................................. 13
2.1 Eén oorzaak? … Allicht niet! ............................................................................................................ 13
2.1.1 DCM: Demands Capacities Model ............................................................................................ 14
2.1.2 Eramus 4-componenten model ................................................................................................ 14
2.2 Theoretische modellen ................................................................................................................... 15
2.2.1 Dual Diathesis-Stressor Model of Developmental Stuttering ...................................................... 15
2.2.2 Onvloeiendheden – model van Levelt ........................................................................................ 17
2.2.3 Covert repair hypothesis .......................................................................................................... 18
2.2.4 Explan ..................................................................................................................................... 19
2.2.5 Vicious circle hypothesis.......................................................................................................... 19
2.2.6 Choking ................................................................................................................................... 20
2.2.7 Multifactorial Dynamic Pathways Theory of Stuttering ............................................................... 20
2.3 Executieve functies (EF) .................................................................................................................. 23
2.3.1 Executieve functies (versus temperament) ............................................................................... 23
2.3.2 Model van werkgeheugen ......................................................................................................... 24
2.3.3 KT geheugen en werkgeheugen ............................................................................................. 24
2.3.4 Inhibitie ............................................................................................................................... 25
2.3.5 Cognitieve flexibiliteit en shifting........................................................................................... 25
1
, 2.3.6 Bevindingen samenvatting .................................................................................................... 25
2.3.7 Executieve functies en stotteren ........................................................................................... 25
2.4 Besluit ..................................................................................................................................... 26
Hoofdstuk 3: Cognities en emoties in de sociale context ........................................................................... 27
3.1 Algemeen....................................................................................................................................... 27
3.2 Angst als leerproces ....................................................................................................................... 29
3.2.1 Wat is angst? ........................................................................................................................... 29
3.2.2 Sociale angst(stoornis)............................................................................................................. 29
3.2.3 Angst – onderhoud ................................................................................................................... 30
3.2.4 Angst als leerproces en vicieuze cirkel ...................................................................................... 31
3.3 Negatieve ervaringen ...................................................................................................................... 32
3.3.1 Stigma – definities ................................................................................................................ 32
3.3.2 Percepties uit omgeving ....................................................................................................... 32
3.3.3 Micro-‘agressies’ ................................................................................................................. 33
3.3.4 Stigma en maskeren/ verbergen............................................................................................ 33
3.3.5 Klinische implicaties ............................................................................................................ 35
3.4 Invloed van temperament ......................................................................................................... 36
3.4.1 Wat is temperament ............................................................................................................. 36
3.4.2 Temperament en stotteren ................................................................................................... 36
3.4.3 Temperament, stotteren en angst ......................................................................................... 37
3.5 Bias en focus.................................................................................................................................. 37
3.5.1 Bias ......................................................................................................................................... 37
3.5.2 Aandacht bias.......................................................................................................................... 38
3.5.3 Interpretatie bias ..................................................................................................................... 38
3.6 Weerbaarheid ................................................................................................................................ 38
3.6.1 Weerbaarheid en stotteren ....................................................................................................... 38
Hoofdstuk 4: Diagnostiek van stotteren .................................................................................................... 39
4.1 Screening ................................................................................................................................ 39
4.2 Diagnostiek ............................................................................................................................. 40
4.2.1 Uitlokkende factoren ............................................................................................................ 40
4.2.2 Uitlokkende factoren → individueel → diagnostiek ................................................................ 41
4.2.3 Demands Capacities Model (DCM) ....................................................................................... 41
4.3 Intake en anamnese ................................................................................................................. 41
4.3.1 ICF-model............................................................................................................................ 42
4.3.2 Anamnese – (gestandaardiseerd) interview ........................................................................... 42
4.3.3 Cognitie, emotie, sociaal ...................................................................................................... 44
4.4 Diagnostische meetinstrumenten............................................................................................. 44
2
, 4.4.1 RIZIV en VVL -BPS................................................................................................................. 44
4.4.2 Meetinstrumenten ............................................................................................................... 45
4.5 Uitlokkende factoren................................................................................................................ 50
4.5.1 Uitlokkende factoren in kaart brengen – overzicht.................................................................. 50
4.5.2 Uitlokkende factoren: spraakmotoriek en taal ....................................................................... 50
4.5.3 Uitlokkende factoren: taal, temperament en omgeving .......................................................... 51
4.6 Goodness-of-fit ....................................................................................................................... 51
4.7 Vanwege rol in therapie – cognitie ............................................................................................. 51
4.8 Advies gesprek ......................................................................................................................... 52
Hoofdstuk 5: Behandeling stotteren ......................................................................................................... 53
5.1 Benaderingen ................................................................................................................................. 53
5.2 Omgaan met negatieve gedachten en emoties ................................................................................ 53
5.2.1 Ouder kind – (jong)volwassen ................................................................................................... 53
5.2.2 Kleuters ................................................................................................................................... 57
5.2.3 Acceptance & commitment therapy (ACT) (3e generatie) ............................................................ 57
5.3 Ouder-begeleiding.......................................................................................................................... 58
5.3.1 Ouders betrekken – waarom? ................................................................................................... 58
5.3.4 Ouder-kind interactie ............................................................................................................... 59
5.3.5 Communicatievaardigheden .................................................................................................... 59
5.3.6 Wat willen ouders voor zichzelf? ............................................................................................... 59
5.3.7 Cognitief-emotionele ondersteuning ........................................................................................ 59
5.3.8 Lotgenoten contact .................................................................................................................. 59
5.4 Verbale therapie: fluency shaping ................................................................................................... 60
5.4.1 Lidcombe programma .......................................................................................................... 60
5.4.2 Restart DCM ........................................................................................................................ 62
5.4.3 Precision Fluency Shaping Program ...................................................................................... 63
5.4.4 ‘Easing into speech’ technieken............................................................................................ 63
5.5 Stottermodificatie .................................................................................................................... 64
5.5.1 Vlot stotteren (‘easing out’)................................................................................................... 65
5.5.2 MIDVAS ............................................................................................................................... 65
5.6 Andere technieken ................................................................................................................... 66
5.6.1 Vloeiendheidsbevorderende technieken ............................................................................... 66
5.7 Welke doelstellingen en aanpak? ............................................................................................. 67
5.7.1 Doelstellingen, vanuit perspectief volwassenen .................................................................... 67
5.7.2 Algemene disability-model ................................................................................................... 68
5.7.3 Micro-agressies ................................................................................................................... 68
5.7.4 Aanvaarding en verandering.................................................................................................. 68
3
, 5.7.5 Dus… welke verandering nastreven....................................................................................... 69
5.7.6 Geïnformeerde keuzes, geen oordeel .................................................................................... 69
5.7.7 Welke doelstelling/aanpak? – besluit .................................................................................... 69
5.8 Evidence Based Practice .......................................................................................................... 70
5.8.1 Huidige klinische aanpak ...................................................................................................... 70
5.8.2 Beleving v therapie door PdS................................................................................................. 70
5.8.3 Evidence-based practice ...................................................................................................... 70
Hoofdstuk 6: Neurologische correlaten bij ontwikkelingsstotteren ............................................................ 73
6.1 DIVA-model ................................................................................................................................... 73
6.1.1 Parallelle representatie v motorische sequentie (bv fonemen) ................................................... 74
6.1.2 Competitive queue model ........................................................................................................ 74
6.1.3 Foneemlijsten ...................................................................................................................... 74
6.1.4 Progressie doorhaan de lijst ................................................................................................. 75
6.1.5 Realistischer scenario .......................................................................................................... 75
6.1.6 Verstoorde selectie/ initiatie ................................................................................................. 76
6.1.7 Onvolledige competitie resolutie .......................................................................................... 76
6.1.8 Initiatie vs articulatie v motoriek ........................................................................................... 77
6.1.9 De ‘actie-selector’: cortico-BG-thalamo-corticale loop ......................................................... 77
6.1.10 Van het CQ-model nr de cortico-BG loop .......................................................................... 78
6.1.11 Bijkomende overweging: sensorimotorische context ......................................................... 78
6.1.12 Stotteren en dopamine ..................................................................................................... 78
6.1.13 GODIVA model ................................................................................................................. 79
6.1.14 Cortico-BG loop spraaksequentie en initiatie .................................................................... 79
6.2 Beeldvorming........................................................................................................................... 80
6.2.1 Neurobiologische theorieën v stotteren .................................................................................... 80
6.2.2 Beeldvorming – grijze stof ......................................................................................................... 80
6.2.3 Beeldvorming – witte stof...................................................................................................... 80
6.2.4 Longitudinale studie, Chang et al. ......................................................................................... 81
6.2.5 DIVA-model en Chang et al. .................................................................................................. 82
6.2.6 Andere studies ..................................................................................................................... 83
6.2.7 (Tijdelijke) vloeiendheidsbevorderende technieken ............................................................... 83
6.2.8 Sensorimotorische coördinatie hersenactiviteit .................................................................... 83
6.2.9 Manipuleren auditieve feedback ........................................................................................... 83
Hoofdstuk 7: Broddelen ........................................................................................................................... 85
7.1 Wat is het?............................................................................................................................... 85
7.2 Diagnostiek ............................................................................................................................. 86
7.2.2 Snelheid en onvloeiendheden observeren ................................................................................. 86
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Prof. Ellen Rombouts – 2024-2025
Hoofdstuk 1: Types van vloeiendheidsstoornissen ...................................................................................... 6
1.1 Vloeiendheidsstoornis ............................................................................................................... 6
1.2 Stotteren en broddelen .............................................................................................................. 6
1.3 Types stotteren .......................................................................................................................... 6
1.4 Ontwikkelingsstotteren .............................................................................................................. 7
1.4.1 Kenmerken ............................................................................................................................ 7
1.4.2 Drie facetten die meespelen ................................................................................................... 7
1.4.3 Insider perspectief ................................................................................................................. 9
1.4.4 Fenomenen bij ontwikkelingsstotteren.................................................................................. 10
1.5 Neurogeen stotteren ................................................................................................................ 10
1.6 Psychogeen stotteren .............................................................................................................. 11
1.7 Farmacogeen stotteren ............................................................................................................ 11
1.8 Geveinsd stotteren................................................................................................................... 12
1.9 Broddelen ................................................................................................................................ 12
Hoofdstuk 2: Hoe ontstaat ontwikkelingsstotteren?.................................................................................. 13
2.1 Eén oorzaak? … Allicht niet! ............................................................................................................ 13
2.1.1 DCM: Demands Capacities Model ............................................................................................ 14
2.1.2 Eramus 4-componenten model ................................................................................................ 14
2.2 Theoretische modellen ................................................................................................................... 15
2.2.1 Dual Diathesis-Stressor Model of Developmental Stuttering ...................................................... 15
2.2.2 Onvloeiendheden – model van Levelt ........................................................................................ 17
2.2.3 Covert repair hypothesis .......................................................................................................... 18
2.2.4 Explan ..................................................................................................................................... 19
2.2.5 Vicious circle hypothesis.......................................................................................................... 19
2.2.6 Choking ................................................................................................................................... 20
2.2.7 Multifactorial Dynamic Pathways Theory of Stuttering ............................................................... 20
2.3 Executieve functies (EF) .................................................................................................................. 23
2.3.1 Executieve functies (versus temperament) ............................................................................... 23
2.3.2 Model van werkgeheugen ......................................................................................................... 24
2.3.3 KT geheugen en werkgeheugen ............................................................................................. 24
2.3.4 Inhibitie ............................................................................................................................... 25
2.3.5 Cognitieve flexibiliteit en shifting........................................................................................... 25
1
, 2.3.6 Bevindingen samenvatting .................................................................................................... 25
2.3.7 Executieve functies en stotteren ........................................................................................... 25
2.4 Besluit ..................................................................................................................................... 26
Hoofdstuk 3: Cognities en emoties in de sociale context ........................................................................... 27
3.1 Algemeen....................................................................................................................................... 27
3.2 Angst als leerproces ....................................................................................................................... 29
3.2.1 Wat is angst? ........................................................................................................................... 29
3.2.2 Sociale angst(stoornis)............................................................................................................. 29
3.2.3 Angst – onderhoud ................................................................................................................... 30
3.2.4 Angst als leerproces en vicieuze cirkel ...................................................................................... 31
3.3 Negatieve ervaringen ...................................................................................................................... 32
3.3.1 Stigma – definities ................................................................................................................ 32
3.3.2 Percepties uit omgeving ....................................................................................................... 32
3.3.3 Micro-‘agressies’ ................................................................................................................. 33
3.3.4 Stigma en maskeren/ verbergen............................................................................................ 33
3.3.5 Klinische implicaties ............................................................................................................ 35
3.4 Invloed van temperament ......................................................................................................... 36
3.4.1 Wat is temperament ............................................................................................................. 36
3.4.2 Temperament en stotteren ................................................................................................... 36
3.4.3 Temperament, stotteren en angst ......................................................................................... 37
3.5 Bias en focus.................................................................................................................................. 37
3.5.1 Bias ......................................................................................................................................... 37
3.5.2 Aandacht bias.......................................................................................................................... 38
3.5.3 Interpretatie bias ..................................................................................................................... 38
3.6 Weerbaarheid ................................................................................................................................ 38
3.6.1 Weerbaarheid en stotteren ....................................................................................................... 38
Hoofdstuk 4: Diagnostiek van stotteren .................................................................................................... 39
4.1 Screening ................................................................................................................................ 39
4.2 Diagnostiek ............................................................................................................................. 40
4.2.1 Uitlokkende factoren ............................................................................................................ 40
4.2.2 Uitlokkende factoren → individueel → diagnostiek ................................................................ 41
4.2.3 Demands Capacities Model (DCM) ....................................................................................... 41
4.3 Intake en anamnese ................................................................................................................. 41
4.3.1 ICF-model............................................................................................................................ 42
4.3.2 Anamnese – (gestandaardiseerd) interview ........................................................................... 42
4.3.3 Cognitie, emotie, sociaal ...................................................................................................... 44
4.4 Diagnostische meetinstrumenten............................................................................................. 44
2
, 4.4.1 RIZIV en VVL -BPS................................................................................................................. 44
4.4.2 Meetinstrumenten ............................................................................................................... 45
4.5 Uitlokkende factoren................................................................................................................ 50
4.5.1 Uitlokkende factoren in kaart brengen – overzicht.................................................................. 50
4.5.2 Uitlokkende factoren: spraakmotoriek en taal ....................................................................... 50
4.5.3 Uitlokkende factoren: taal, temperament en omgeving .......................................................... 51
4.6 Goodness-of-fit ....................................................................................................................... 51
4.7 Vanwege rol in therapie – cognitie ............................................................................................. 51
4.8 Advies gesprek ......................................................................................................................... 52
Hoofdstuk 5: Behandeling stotteren ......................................................................................................... 53
5.1 Benaderingen ................................................................................................................................. 53
5.2 Omgaan met negatieve gedachten en emoties ................................................................................ 53
5.2.1 Ouder kind – (jong)volwassen ................................................................................................... 53
5.2.2 Kleuters ................................................................................................................................... 57
5.2.3 Acceptance & commitment therapy (ACT) (3e generatie) ............................................................ 57
5.3 Ouder-begeleiding.......................................................................................................................... 58
5.3.1 Ouders betrekken – waarom? ................................................................................................... 58
5.3.4 Ouder-kind interactie ............................................................................................................... 59
5.3.5 Communicatievaardigheden .................................................................................................... 59
5.3.6 Wat willen ouders voor zichzelf? ............................................................................................... 59
5.3.7 Cognitief-emotionele ondersteuning ........................................................................................ 59
5.3.8 Lotgenoten contact .................................................................................................................. 59
5.4 Verbale therapie: fluency shaping ................................................................................................... 60
5.4.1 Lidcombe programma .......................................................................................................... 60
5.4.2 Restart DCM ........................................................................................................................ 62
5.4.3 Precision Fluency Shaping Program ...................................................................................... 63
5.4.4 ‘Easing into speech’ technieken............................................................................................ 63
5.5 Stottermodificatie .................................................................................................................... 64
5.5.1 Vlot stotteren (‘easing out’)................................................................................................... 65
5.5.2 MIDVAS ............................................................................................................................... 65
5.6 Andere technieken ................................................................................................................... 66
5.6.1 Vloeiendheidsbevorderende technieken ............................................................................... 66
5.7 Welke doelstellingen en aanpak? ............................................................................................. 67
5.7.1 Doelstellingen, vanuit perspectief volwassenen .................................................................... 67
5.7.2 Algemene disability-model ................................................................................................... 68
5.7.3 Micro-agressies ................................................................................................................... 68
5.7.4 Aanvaarding en verandering.................................................................................................. 68
3
, 5.7.5 Dus… welke verandering nastreven....................................................................................... 69
5.7.6 Geïnformeerde keuzes, geen oordeel .................................................................................... 69
5.7.7 Welke doelstelling/aanpak? – besluit .................................................................................... 69
5.8 Evidence Based Practice .......................................................................................................... 70
5.8.1 Huidige klinische aanpak ...................................................................................................... 70
5.8.2 Beleving v therapie door PdS................................................................................................. 70
5.8.3 Evidence-based practice ...................................................................................................... 70
Hoofdstuk 6: Neurologische correlaten bij ontwikkelingsstotteren ............................................................ 73
6.1 DIVA-model ................................................................................................................................... 73
6.1.1 Parallelle representatie v motorische sequentie (bv fonemen) ................................................... 74
6.1.2 Competitive queue model ........................................................................................................ 74
6.1.3 Foneemlijsten ...................................................................................................................... 74
6.1.4 Progressie doorhaan de lijst ................................................................................................. 75
6.1.5 Realistischer scenario .......................................................................................................... 75
6.1.6 Verstoorde selectie/ initiatie ................................................................................................. 76
6.1.7 Onvolledige competitie resolutie .......................................................................................... 76
6.1.8 Initiatie vs articulatie v motoriek ........................................................................................... 77
6.1.9 De ‘actie-selector’: cortico-BG-thalamo-corticale loop ......................................................... 77
6.1.10 Van het CQ-model nr de cortico-BG loop .......................................................................... 78
6.1.11 Bijkomende overweging: sensorimotorische context ......................................................... 78
6.1.12 Stotteren en dopamine ..................................................................................................... 78
6.1.13 GODIVA model ................................................................................................................. 79
6.1.14 Cortico-BG loop spraaksequentie en initiatie .................................................................... 79
6.2 Beeldvorming........................................................................................................................... 80
6.2.1 Neurobiologische theorieën v stotteren .................................................................................... 80
6.2.2 Beeldvorming – grijze stof ......................................................................................................... 80
6.2.3 Beeldvorming – witte stof...................................................................................................... 80
6.2.4 Longitudinale studie, Chang et al. ......................................................................................... 81
6.2.5 DIVA-model en Chang et al. .................................................................................................. 82
6.2.6 Andere studies ..................................................................................................................... 83
6.2.7 (Tijdelijke) vloeiendheidsbevorderende technieken ............................................................... 83
6.2.8 Sensorimotorische coördinatie hersenactiviteit .................................................................... 83
6.2.9 Manipuleren auditieve feedback ........................................................................................... 83
Hoofdstuk 7: Broddelen ........................................................................................................................... 85
7.1 Wat is het?............................................................................................................................... 85
7.2 Diagnostiek ............................................................................................................................. 86
7.2.2 Snelheid en onvloeiendheden observeren ................................................................................. 86
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